Med Surg Final!

Hyperkalemia ECG changes

(1) Tall, peaked T-waves (2) Widened QRS complex, PVCs, Ventricular fibrillation, Cardiac standstill/asystole (3) prolongation of the P wave wider than normal & PRI longer than normal. (4) Flattens P wave or loss of P wave as the values go up.

Hypocalcemia ECG Changes

(1) Variable (2) Bradycardia (3) V-tachycardia (4) Asystole

Hypokalemia Mechanisms

(1) impairs myocardial conduction (2) Prolongs ventricular repolarization

Hypomagnesemia Mechanisms

(1) impairs myocardial conduction (2) Prolongs ventricular repolarization (3) May lead to coronary artery spasm, hypertension

Depth of heart damage with MI

(1)Transmural - full thickness of heart (endocardium, myocardium, epicardium) (2)Non-transmural - involves limited amount of cardiac tissue; subendocardial, endocardial, epicardial, subepicardial infarction

Magnesium

(1.3-2.4 mEq/L) A. Actions 1. Essential for enzyme, protein, lipid, and carbohydrate functions in the body 2. Extracellular level essential for normal cardiac muscle function -Hypermagnesemia (>2.4 mEq/L) -Hypomagnesemia (<1.3 mEq/L) more common

Potassium

(3.5-5 mEq/L) A. Actions: 1. K+ and NA+ pump intracellularly / extracellularly 2. Determines conduction velocity 3.Helps to confine pacing activity to the SA node 4.Excess or deficiency can alter myocardial muscle function B. Imbalances: -Hyperkalemia (>5.0 mEq/L) -Hyppokalemia (<3.5 mEq/L)

Management of Atrial Flutter

-Cardiology consult recommended -Anticoagulant therapy unless contraindicated (heparin, coumadin etc.) -Ventricular rate control: Medications, Synchronized cardioversion -Interventional radiology: ablation of irritable site -Rate control with medications: Amiodarone(anti-dysrhythmic), beta-blocker (metaprolol tartrate)

Management of PAC

-Occasional PACs usually do not require treatment -Frequent PACs may induce episodes of atrial fibrillation or PSVT -Frequent PACs are treated by correcting the underlying cause: Correcting electrolyte imbalances, Reducing stress ,Reducing or eliminating stimulants, Treating heart failure

CMs of Chronic liver failure

-Onset is insidious -Fatigue* (early symptom) -Many have no symptoms until late in progression -Ascites: Protein rich fluid accumulates in abdominal cavity, >500 mL, increased abdominal girth, abd pain, bloating, SOB, May develop pleural effusions -Portal hypertension and varices: Enlargement of veins - esophagus (varices), skin of abdomen, veins in rectum and anus (hemorrhoids), Presentation - ascites, confusion, GI bleeding -Hepatic encephalopathy: Disturbances in CNS change LOC to seizures and coma, Causes: increased ammonia, dehydration, excessive diuresis, infection, sedatives or antianxiety medications -Coagulopathy : Thrombocytopenia, prolonged PT, May develop disseminated intravascular coagulation -Hepatorenal syndrome: Some develop, Rapid deterioration of kidney function, May have normal UOP or oliguria but elevated creatinine and BUN -Spontaneous bacterial peritonitis: Fever, abdominal pain, encephalopathy or acute hemodynamic decompensation, Diagnosis - culture of ascitic fluid -Jaundice -Peripheral edema (Late manifestation)

Penetrating Trauma

-Open wound through the chest wall and the pleural space and disrupts that and allows air or blood or other fluid into that space. -Can be superficial or life threatening

Medical Management of Shock

-Oxygen & ventilation -Fluid Resuscitation -Nutrition -Medications: Vasopressors, Vasodilators, Other Medications

Medical Management of Pulmonary Hypertension

-Oxygen (target O2 sat 90% or greater) -Symptom limited physical activity Note: -Avoid use of beta-blockers, decongestants may cause vasoconstriction -If on sildenafil - no nitrates

Other Management for Sepsis

-PRBC transfusion -Corticosteroid therapy (hydrocortisone) -Ventilatory support -Nutritional support (start within 48 hours) -Metabolic support - tight glycemic control BS <140 -Dialysis prn -DVT & stress ulcer prophylaxis -Bicarbonate IV to treat lactic acidosis -Set goals for end-of life care with patient/ family

Nursing Management for removal of pulmonary artery catheter

(a) Recommend trendelenburg position at removal (b) Remove sutures and dressing (c) Have client take deep breath and hold during withdrawal of catheter (d) Apply pressure with sterile gauze for 3-5 minutes or until hemostasis achieved (e) Monitor for bleeding (Subclavian vein not compressible and at greater risk to bleed)

Nursing implications Obtaining measurements

(a) Zero system at beginning of each shift (b) Level at phlebostatic axis with head elevation 0-45 degrees (up to 90 degrees) prior to each reading (c) PAP: at end expiration (d) PWP: slowly inflate balloon with air until PA waveform changes to PWP waveform (e) Never inflate balloon with more than 1.5 mL (f) Do not inflate for more than four respiratory cycles or 8-15 seconds (g) Leave balloon lumen deflated and locked position except for intermittent reading

Mechanical valve replacement

(artificial) may hear a clicking sound with this one. -Last longer -Risk of thromboembolism -Require life-long anticoagulation

Assess regularity

(atrial and ventricular) a. P to P interval (atrial regularity) b. R to R interval (ventricular regularity) c. If interval varies more than 3 small squares, considered irregular.

Stroke

(brain attack or cerebrovascular accident (CVA)) -Blockage in blood vessel (ischemic): Cerebral anoxia>10 minutes causes cerebral infarction with irreversible changes. -Bleeding into brain (hemorrhagic) Risk Factors: -Hypertension -Cigarette smoking -Serum Cholesterol -Stress -Emboli: atrial fibrilation, recent MI, ventricular aneurysm, cardiomyopathy (clots in the chambers), heart valves. -Heart failure -Endocarditis

Biventricular pacing

(cardiac resynchronization therapy(CRT)) -Resyynchronizes cardiac cycle by pacing both ventricles -Can be combined with ICD for maximum therapy -Used in severe heart failure -3 pacing wires (right atrium, right ventricle, left ventricle [via coronary vein to left ventricle]). -Coordinates contraction of RV and LV and increases LV function and output.

Risk Factors for peptic ulcers

(cause destruction of mucosal barrier) -Helicobacter pylori (h pylori) -Aspirin and NSAIDS -Excessive smoking and alcohol intake -Other medications: steroids with NSAIDS, Potassium chloride, bisphosphates. -Neoplasia -Hyperparathyroidism -Critically ill patients with burns, head injury, physical trauma, or multiple organ failure. Stress-related mucosal disease: Stress ulcer (physiologic): -Diffuse superficial mucosal injury or discrete deeper ulcers in stomach. -Related to ischemia (hemorrhage, trauma, burn [Cushing's ulcer]) -Related to decreased mucosal blood flow and hyper-secretion of acid (head trauma, brain surgery).

Traumatic Blunt Pneumothorax

(closed) non penetrating chest trauma, such as broken rib. -Lung laceration

Tumor Lysis Syndrome

Oncological Emergency. Occurs when large quantities tumor cells destroyed rapidly & intracellular components (K+ & uric acid) faster than can be eliminated Occurs 24-48 hours after chemotherapy; persists 5-7 days CMs: -Related to metabolic imbalances: Hyperkalemia Hypocalcemia Hyperphosphatemia Hyperuricemia (may lead to AKI Early signs - weakness, muscle cramps, diarrhea, nausea, vomiting Interventions: -Encourage oral hydration, & IV's as prescribed Monitor renal function, I&O, electrolytes, ECG changes Place on renal diet low in K+ & phosphorous Administer diuretics to increase urine flow Administer meds to increase excretion purines (allopurinol) Reduce K+ level (glucose & insulin, dialysis)

Core Measures for MI

(1) ASA aspirin at arrival (2) ASA aspirin prescribed at discharge (3) ACEI or ARB for LVSD left ventricular systolic dysfunction discharged on this if it is below normal. (if EF < 40%) (4) Adult Smoking Cessation Advise/Counseling (5) Beta Blocker prescribed at discharge (6) Median time to fibrinolysis (7) Fibrinolytic therapy received within 30 minutes of hospital arrival (8) Median time to PCI (9) Primary PCI received within 90 minutes of hospital arrival (10) Statin at discharge (to achieve LDL < 100)

Hypercalcemia Causes

(1) Bone tumors (2)Hypomagnesemia (3) endocrine disorders (4) excessive intake of vitamin D or Ca++

Hypocalcemia Mechanisms

(1) Decreases myocardial contractility (2) Reduces cardiac output (3) Hypotension (4) Decreases responsiveness to Digitalis monitor K+

Hyperkalemia Mechanism

(1) Decreases rate of ventricular depolarization (slows) expect the ventricular rate to decrease. (2) Shortens repolarization (accelerates) speeding up their returning back to base line so ventricular arrhythmias can occur. (3) Depresses AV conduction would slow the conduction and prolong the PR interval.

Complications of Pulmonary Artery Catheter

(1) Dysrhythmias (insertion or migration) (2) Pneumothorax (3) Pulmonary infarction (4) Pulmonary artery rupture (5) Air embolism (6) Thrombosis (7) Bleeding (8) Knotting of catheter (9) Central line bloodstream infection (10) Right heart/valve trauma

Hyperkalemia Causes

(1) Excess K+ administration (2) K+ sparing diuretics, ACE inhibitors, ARB drugs (3) Renal failure (4) Acidosis (5) Extensive skeletal muscle destruction (trauma) (a) Rhabdomyolysis: A breakdown of muscle tissue that releases a damaging protein into the blood. (6) Burns

Hypokalemia Causes

(1) GI losses (2) Renal dysfunction (3) Alkalosis (4) Diuretic therapy with insufficient replacement (5) Chronic steroid therapy

Hypomagnesemia Causes

(1) Insufficient intake (2) ETOH abuse (3) Diuresis/diarrhea Rapid administration of citrated blood products (4) Rapid administration of citrated blood products

Hypokalemia Management

(1) K+ replacement (10 mEq per hour) a. High Alert Medication b. NEVER IV push c. Dilute K+ sufficiently & administer slowly would have a bolus, given as a piggyback. d. Monitor for phlebitis: try to give through central line if possible however if given through a peripheral line can be irritating to the blood vessel monitor for phlebitis. (2) If hypomagnesemia exists, Mg+ replacement must take place before K+ replacement can be successful

Uses for Pulmonary Artery Catheter

(1) Measure CVP (central venous pressure) /RAP, PAP (pulmonary artery pressure) (PAS systolic, PAD diastolic, PAM mean), PWP Pulmonary wedge pressure (when you inflate the balloon it seals off so that no information can come from behind where that balloon is), CO cardiac output/CI cardiac index, SVO2, core temperature; and derived measurements: PVR pulmonary vascular resistance (right side of the heart), SVR systemic vascular resistance (left sided of the heart), SV stroke volume (2) Obtain information about right and left sides of the heart (3) Obtain information about preload, afterload, and contractility (4) Manage hemodynamically unstable clients

Values for Pulmonary Artery Catheter

(1) PA systolic pressure - measures right ventricular systolic ejection (amount of pressure needed to open the pulmonic valve) PAS 20-30 mmHg (2) PA diastolic pressure - represents the resistance of pulmonary vascular bed after pulmonic valve has closed; Under normal conditions reflect left ventricular end-diastolic pressure PAD 6-10 mmHg (3) PWP (PAWP) - reflects left atrial and left ventricular pressures; PWP obtained when balloon is inflated on the tip of the PA catheter PWP 4-12 mmHg

Hypokalemia ECG changes

(1) PVCs, bradycardia, ventricular tachycardia, prolonging ventricular repolarization makes the environment right for other arrhythmias to develop. (2) Prolonged QT interval (predisposes to Torsades de pointes) Seeing the ventricular repolarization time take longer than normal that's what's causing that to be prolonged. (3) Deterioration V Tach into V-fib (4) Depressed T-waves, inverted T-waves, ST depression (5) U waves (positive wave after T wave) (6) 2 degree and 3 degree heart blocks

Hypocalcemia Causes

(1) Post-surgical, blood transfusions (2) Alkalosis (metabolic) (3) Shock (4) Magnesium imbalances (5) Hypocalcemia - QT Intervals

Hypocalcemia Management

(1) Seizure precautions (2) Oral and IV replacement (3) Calcium chloride (4) Calcium gluconate

Acute Kidney Injury

(AKI) -Sudden loss of renal function -Accumulation of nitrogenous waste products Causes main ones: -Acute illness -Major surgery -Cardiovascular disease -Diabetes Mellitus -Sepsis -Contrast media -Exposure to nephrotoxins -Aging

Fraction of Inspired Oxygen

(FiO2): a) Amount of oxygen client receives via mechanical ventilator b) Set between 21 - 100%

Premature Atrial Contractions

(PACs) ECG Characteristics: S= sinus beats -Ventricular/atrial Regularity: Irregular whenever PAC beat occurs -Ventricular/atrial Rate(s): Depends on underlying rhythm -P waves: Premature (occurring earlier than the next expected sinus P wave), positive (upright) in lead II, one before each QRS complex, often differ in shape from sinus P waves-may be flattened, notched, pointed, biphasic, or lost in the preceding T wave -PR Interval: 0.12 to 0.20 sec but varies in the PAC -QRS Duration: 0.04 to 0.10 sec unless abnormally conducted

Transphenoidal Hypophysectomy

(TPH) -Pituitary tumor removal -Nasal cavity approach -Adipose tissue graft to prevent CSF leak -Nasal packing Complications: -Increased intracranial pressure -Air embolism -CSF leak: meningitis -Diabetes Insipidus -Visual disturbances -Infection

Nursing management for pulmonary artery catheter

(a) Keep handling of line to minimum (b) Change irrigation fluid, pressure tubing with transducer per hospital guidelines (c) Change transparent dressing per hospital guidelines (average every 7 days) (d) Utilize proximal lumen to measure RAP, infuse IV fluids, sample blood, infuse IV meds (e) Utilize distal lumen to measure PA pressures - lumen not used for IV fluids, only irrigation fluids (<300 mm3)

Anaphylactic Shock

(form of distributive shock) An allergic reaction to some agent causes massive vasodilation within the body -Causes: any medication, food, chemical, or substance that can illicit an allergic response (peanuts, contrast dyes, bees). -Hemodynamics & CMs: Hypotension, Tachycardia, Decreased CO, Decreased RAP, Decreased SVR Decreased SVO2, Chest pain, SOB, edema of larynx and epiglottis, wheezing, stridor, flushing, urticaria,angioedema, decreased LOC, abdominal pain, N/V/D -Diagnostic Procedures: Sudden onset, increase in inflammatory response. -Management/ treatment: Immediately remove trigger Oxygen (if needed, Intubation and mechanical ventilation) Circulatory support w/IV fluids Epinephrine IV - first line med Vasopressin, Antihistamines Bronchodilators, Steroids

Low Pressure

(low exhaled volume) Causes: a. cuff leak or deflated b. Leak in ventilator circuit or tubing disconnect c. tube displacement d. Client stops breathing in PSV or SIMV mode Troubleshooting/Interventions: a. Assess for cuff leak, check cuff pressure, re-inflate to minimal occluding volume, notify RT b. Assess all connections and tubing connections. c. Assess tube placement and breath sounds d. Assess client; notify HCP.

Traumatic Penetrating Pneumothorax

(open) could be a stab wound, gun shot wound, etc. -Can cause a sucking chest wound. -Apply vent dressing it is secured only on three sides during inspiration it prevents air from entering into the pleural space and on expiration will allow the air to move out efficiently until it is fixed. -Do not remove impaled object.

Percutaneous transluminal balloon Valvuloplasty

(plasty think of a balloon) (non-surgical). 1) Invasive, non-surgical intervention 2) Used for aortic or mitral valve when there is stenosis to try and make a bigger opening. 3) Monitoring after procedure: -Assess ECG rhythm, heart sounds (would still expect to hear a murmur), CO -Complications: bleeding, emboli, regurgitation

Sinus Bradycardia assessment and management

- Assess client tolerance of bradycardia - Assess for low cardiac output -Change LOC, chest pain, hypotension, SOB, respiratory distress, dizziness/syncope, fatigue, restlessness Management for symptomatic bradycardia: -Atropine** increases heart rate -Isoproterenol -Pacemaker -Asymptomatic: continue to monitor them.

Management of Atrial Tachycardia

- Assess if client is symptomatic. If symptomatic: -Apply pulse oximeter and oxygen if indicated -Obtain vital signs -Establish IV access -Obtain 12-lead ECG -Vagal stimulation maneuvers -Adenosine* -Beta-blockers -Calcium channel blocker -Amiodarone -Synchronized cardioversion if hemodynamic compromise

Management of Atrial Fibrillation

- Cardiology consult recommended - Anticoagulation recommended if A Fib has been present for 48 hours or longer for 4-6 weeks. -Ventricular rate control: Emergent synchronized cardioversion if hemodynamic instability and not responsive to medications, Medications - Calcium channel blockers (verapamil), beta blockers, Digoxin, Amiodarone -Surgical - MAZE procedure

Cms of Diabetes Insipidus

- Depend on amount of water loss -Polyuria: dilute urine - Neuro cause >6L/day, nephrogenic cause 8-10 L/day -Polydipsia -Nocturia -Hemoconcentration leading to lab alterations: Hypernatremia, Increased hematocrit -Dehydration - thirst, decreased skin turgor/tenting, fatigue -Tachycardia, hypotension, hypovolemia

ST segment

- Distance between the end of S wave and beginning of T wave. - Measures the time between ventricular depolarization and beginning of repolarization -Baseline, elevated, or depressed Look for depression or elevation or isoelectric, if it is: -ST elevation: myocardial injury -ST depression: reciprocal changes, digoxin, and ischemia.

ECG waves, Complexes, Segments, Intervals

- P wave - PR interval - QRS complex -QRS Interval - ST segment -T wave -Qt interval

Nursing Actions for Pulmonary Embolism

-Administer anticoagulants as prescribed monitor the appropriate lab values as prescribed ad well. -Administer thrombolytics if ordered: used in interventional radiology. Chances are we would not administer them at the bed side as often. -Administer inotropic agents if ordered so increase cardiac contractility and overcome the dysfunction in the ventricles. -Implement bleeding precautions typically also monitor urine, stool, and sputum for any signs of bleeding as well as looking for any bruising. -Increase head of bed this would allow the diaphragm to drop and hopefully reduce the work of breathing for the individual and help improve their oxygenation as best as we can. -Administer IV fluids want keep the viscosity of the blood decreased so it has a less tendency to clot. and be careful not to use too much fluid and lead to fluid volume overload.

Nursing interventions actions for pacemaker

-Administer prophylactic antibiotic (if ordered) -Troubleshoot pacemaker -Allow the client out of bed when stable -Limit the client's arm and shoulder activity (on operative side: permanent pacemaker) -Prepare for discharge in 1-2 days

Risk Factors for Endocarditis

-Age>60 there are changes with the aortic valve that can occur and people in this age do have some sort of aortic stenosis. -Immunosuppression -Presence of prosthetic valves -Previous history of endocarditis more likely to have a recurrence -Congenital heart disease usually related to the fact that they have some structural abnormalities that puts them at greater risk. -IV drug abuse second most common cause of this. -Presence of an intravascular device can try and prevent this by infection control. -Rheumatic Heart Disease -Dental Procedures -Invasive procedures work to prevent health care associated infections.

Acute Pancreatitis

-An acute inflammatory process of the pancreas. -Varies from mild to severe: Mild: self limiting, no end organ involvement. Severe: auto digestion leads to bleeding and necrosis. Causes: -Gallbladder disease [biliary disease] stones (women)* -Chronic alcohol intake (men)* -Trauma* *most common causes Less common causes: -Medication reactions -Pancreatic obstructions (tumors, cysts, abscess) -Metabolic disorders (increased triglycerides, calcium) -Renal failure -Infections (viral [common cause of death], cysts, abscesses). -Idiopathic: unknown causes.

Medications for chest trauma

-Analgesics -Antibiotics (prophylactic: penetrating trauma)

Teaching with Mitral valve prolapse

-Antibiotic prophylaxis if MR mitral regurgitation present -Take drugs as prescribed -Healthy diet; avoid caffeine -Avoid OTC stimulants -Exercise -When to call health care provider

Management First Degree AV Block

-Assess for cause and treat -Assess for changes in PRI

Thermal Burns

-Cause: Flame, flash, scald or direct contact. -Most common type of burn. -Severity of injury depends on: Temperature burning agent and duration contact, amount tissue exposed, age patient. -Injuries: skin injuries depending on depth.

Epicardial pacing

-Leads placed on epicardium during heart surgery -Passed through chest wall and attached to external power source as needed.

Hypertensive Urgency

-Occurs over days to weeks slower onset -BP > 180/120 -No evidence of target organ disease -Comes on slowly and body seems to compensate and doesn't impact the different organs.

Types of Pneumothorax

-Spontaneous -Iatrogenic -Traumatic penetrating -Traumatic blunt -Alveolar rupture

Premature Ventricular Contractions

-Wide and bizarre beats -Compensatory pause Patterns: Bigeminy and trigeminy, couplets and triplets -Unifocal vs. Multifocal -Early beat that interrupts the underlying rhythm. (PVCs) ECG Characteristics: -Ventricular/atrial Regularity:Irregular whenever PVC occurs -Rate: Depends on rate of underlying rhythm -P waves: None associated with PVCs -PR Interval: None associated with PVC -QRS Duration: Greater than 0.10 sec

ECG graph made up of small and larger, heavy-lined squares

-smallest squares are 1 mm wide and 1 mm high -5 small squares between the heavier black lines -25 small squares within each large square

Tissue Oxygenation Monitoring

1) Arterial oxygen saturation (SaO2) represents the actual amount of oxygen bound to Hgb divided by the maximum amount oxygen that could bind to Hgb; measure with pulse oximetry (2) Mixed venous oxygen saturation (SVO2) reflects the oxygen saturation of Hgb in venous blood returning to heart; SVO2 60-75%; Requires PA catheter (3) Central venous oxygen saturation (ScVO2) utilizes central line and specialized monitor

Medications for Acute Respiratory Failure

1) Bronchodilators methylpredinisolone: Open airways, increase airway diameter 2)Steroids: Decrease inflammatory response, decrease bronchoconstriction, increase airway diameter 3) Diuretics especially if they have any edema: Decrease pulmonary congestion 4) Sedation:Control agitation and anxiety to help reduce work of breathing 5) Antibiotics:Initially broad spectrum for suspected pneumonia then adjusted if positive for bacterial infection. 6) may use nitroglycerin as well.

Prevent Contrast-Induced nephropathy (CIN) for acute kidney injury

1) Extensive hydration before and after any procedure using contrast media 2) Patients at high risk may receive oral acetylcysteine with oral hydration 3) Avoid diuretics during this time 4) Stop nephrotoxic drugs (aminoglycoside antibiotics, NSAIDs, chemotherapeutic agents) prior to procedure

Prevent additional Kidney damage for acute kidney injury

1) Modify medication dosing (drugs metabolized or excreted by kidney 2) Monitor peak and trough levels of select medications 3) Administer antihypertensives as needed: -Most antihypertensives not removed by RRT -During hemodialysis, adjust dosage schedule to avoid hypotensive episodes during dialysis -Some antihypertensives eliminated by kidneys and will require alterations in dosage or dosing schedule.

Cardiac output monitoring

1) Normal values (a) Cardiac output - volume of blood ejected by heart over 1 min; CO 4-6 L/min; CI 2.5-4 L/min/m2 (b) Systemic vascular resistance - measures the afterload of the left ventricle; SVR 800-1200 dynes/sec/cm5 (c) Pulmonary vascular resistance - measure the afterload of the right ventricle; PVR < 250 dynes/sec/cm5 (d) Ejection fraction (EF) measurement of percentage of blood leaving the heart each contraction EF 55-70% normal

Standard Chest Leads

1. - V1, V2, V3, V4, V5, V6 a. View heart in horizontal plane in directions (anterior, posterior, right, left) v1: fourth intercostal space at the right sternal border.

Management of Addison's

1. Addison's disease a. Glucocorticoids and/or mineralocorticoids b. Monitor for Addison's crisis c. Require lifelong glucocorticoid replacement and possibly lifelong mineralocorticoid replacements d. Increased corticosteroid replacement needed in times of stress e. Diet - high protein & carbohydrates, calcium and Vit D supplements 2. Addison's crisis a. IV glucocorticoids b. IV fluids and management electrolyte imbalances c. After crisis resolved, convert to oral glucocorticoids and mineralocorticoids

Background Defibrillation

1. An unsynchronized shock used to terminate ventricular fibrillation, not synchronized with any part of the electrical 2. Most effective when completed within 2 minutes of dysrhythmia onset 3. Passage of direct current (DC) electrical shock through the heart to depolarize all the cells of the myocardium what we are trying to do is restore normal heart rhythm by depolarizing all the cells in the heart the cells that have the quickest recovery time from the electrical impulses being spread would be the SA node so you are hopeful that the SA Node then will recover from that impulse and will fire again and thus eliminate the pulseless v tach or v fib. 4. Allows SA node to resume pacemaker role

Medications used in conjunction with ventilation

1. Analgesics: Morphine 2. Sedatives: benzodiazepines, neuroleptics, and Propofol 3. Neuromuscular blocking agents: paralytic agents 4. Refer to: HANDOUT "Sedation and Neuromuscular Blockers"

Indications for Mechanical Ventilation

1. Apnea or impending inability to breathe 2. Acute respiratory failure 3. Severe hypoxia (refractory hypoxemia) 4. Respiratory muscle fatigue 5. Apnea, respiratory arrest 6. Secretion and airway control 7. May be ethical decision to use or not

Electrode Placement

1. Application of electrodes: a. Explain to client b. Check equipment & electrodes c. Prep skin: use soap and water, a lot of hair use clippers, do not use alcohol it can irritate the skin. d. Place electrodes 2. Three-Wire Cable a. Monitor leads I, II, III b. Place electrodes - RA, LA, LL 3. Five-Wire Cable a. Monitor Leads I, II, III, aVR, aVL, aVF and one chest lead usually V1 4. Modified Chest Leads a. MCL1 - simulates V1 and views the ventricular septum b. MCL6 - simulates V6 and views lateral wall of left ventricle 5. 12-Lead ECG 6. Other Placements - Right sided 12-Lead ECG, 15-Lead ECG

Nursing Implications Pre-Procedure for cardiac cath

1. Assessment/Actions a. NPO 6-8 hours b. Adjusted doses insulin/hypoglycemics day of procedure c. Benadryl to prevent allergic reaction to dye d. ASA, Clopidogrel or platelet inhibitor may be given e. May give anxiolytic medication f. Assess baseline vital signs and peripheral pulses 2. Teaching a. Expected duration and activities to expect b. Potential expectation "hot flash" at time of dye injection c. Will be awake during procedure

Electrophysiology

1. Automaticity 2. Excitability 3. Conductivity 4. Depolarization 5. Repolarization 6. Resting State

Rules for ABG Interpretation

1. CO2 is always acid (acidotic) 2. HCO3 is always base (alkalotic) 3. Only the lungs can manipulate the CO2: the respiratory parameter 4. Only the kidneys can manipulate the HCO3: the metabolic parameter 5. Acid Base Mnemonic (ROME) R Respiratory O Opposite 1) increase pH PCO2 decrease Alkalosis 2) pH decrease PCO2 increase Acidosis M Metabolic E Equal 1) pH increase HCO3 increase Alkalosis 2) pH decrease HCO3 decrease Acidosis

Classification of Burns

1. First Degree: Superficial: -Involves epidermis -Erythema and hypersensitivity (24 - 72 hours) -Heals in 3 - 7 days without treatment -Not calculated for fluid resuscitation 2. Second Degree: Superficial partial-thickness: -Involves epidermis and superficial layers of dermis -Blisters that may weep -Heal 1-2 weeks 3. Third Degree: Deep partial-thickness: -Involves the epidermis and deeper layers of dermis -Heals in 3 - 6 weeks -Scarring 4. Fourth Degree: Full-thickness: -Involves all skin elements, nerve endings, fat, muscle, bone -Thick, dry, leathery appearance (eschar) -Always requires excision and skin grafting for wound closure

Normal values with central venous catheter

1. Mean right atrial pressure 2-6 mmHg 2. Estimate of right ventricular filling pressure or volume returning to right heart 3. Influenced by intravascular volume, venous tone, venous return, sympathetic response, intrathoracic pressure, right heart function

Complications of Mechanical Ventilation

1. Misplaced ETT right mainstem bronchus 2. Unplanned extubation 3. Hypotension a) Decreased venous return to heart -> decreased cardiac output b) Sedatives and opioids may contribute 4. Infection: Bypassed normal defenses of upper and lower airway 5. Barotrauma: Alveolar rupture -> tension pneumothorax 6. Aspiration: a)Aspiration prevention: -Maintain HOB elevation 30-45 degrees unless contraindicated - Use sedatives sparingly -For tube-fed clients, assess placement of feeding tube at 4-hour intervals -For clients receiving gastric tube feedings, assess for gastrointestinal intolerance to feedings at 4-hour intervals -For tube-fed clients, avoid bolus feedings in those at high risk for aspiration. -Obtain swallow evaluation before oral feedings started for recently extubated clients who had been intubated for more than 2 days -Maintain endotracheal cuff pressure at appropriate level, and ensure that secretions are cleared above the cuff before it is deflated 7.Ventilator-associated pneumonia (VAP): a) Occurs 48 hours or more after intubation b) Risk factors: Contaminated respiratory equipment, inadequate hand washing, environmental factors, impaired cough, colonization of oropharynx c) VAP Prevention (Ventilator bundle): -Identify clients where NIPPV may be appropriate to prevent need for intubation -Assess readiness extubate daily through Spontaneous awakening trials (sedation vacations) and spontaneous breathing trials. -Maintain and improve physical conditioning through early exercise and mobility -Elevated head of bed 30 - 45 degrees unless medically contraindicated -Minimize pooling of secretions above the endotracheal tube cuff using continuous subglottic suction -Change ventilator circuits only if visibly soiled, no routine changes -Oral hygiene: Brush teeth, gums, and tongue at least twice a day, Provide oral moisturizing to oral mucosa and lips every 2-4 hours, Use oral chlorhexidine gluconate (0.12%) rinse twice a day in intubated clients -Peptic ulcer disease prophylaxis -Deep vein thrombosis prophylaxis

Pacemaker Settings

1. Rate: Usually 60-80 beats per minute to maintain adequate cardiac output. 2. Mode: a) Demand/synchronous comes when it is needed. b) Fixed rate/asynchronous 3. Electrical output: milliamperes (mA): Amount of electrical current delivered to reach "threshold" and achieve "capture" 4.Sensitivity: a)The degree to which the pm is responsive to electrical activity of heart 5. Sense-pace indicator on temporary pacing. a) Indicates when intrinsic beat sensed b) Indicates when paced impulse is delivered 6. AV interval: a) Time interval between atrial & ventricle pacing stimuli

Ventilation/Perfusion Ratio

1. Ventilation: V 2. Perfusion: Q 3. Alveolar ventilation is 4 L/min 4. Pulmonary capillary perfusion is 5 L/min 5. Which equals to = 0.8 ratio, more perfusion than ventilation 6. V/Q < 0.8 a) a decrease in ventilation in relation to perfusion has occurred. b) similar to right to left shunt c) more deoxygenated blood is returning to the left heart d) Mucous plug 7. V/Q > 0.8: 0.8 have a problem with blood flow there could be little to no blood flow such as a PE there could be impaired blood flow due to the patient being hemodynamically impaired in situations such as cardiogenic shock. a) a decrease in perfusion in relation to ventilation b) pulmonary emboli, cardiogenic shock

Gas Exchange

1. pH - Normal 7.35 - 7.45 a) <7.35 acidosis b) >7.45 alkalosis 2. PaCO2 - respiratory component - Normal 35-45 3. HCO3 - metabolic component - Normal 22-26 4. Base excess and base deficit - reflect metabolic contribution to acid-base balance -Normal -2 to +2 5. See Handout "Acid Base Abnormalities" for Acid Base Abnormalities (Causes, clinical manifestations, collaborative management) 6. Critical values a) PaO2 < 60 mmHg b) PaCO2 > 50 mmHg c) pH <7.25 or 7.60 d) SaO2 < 90%

Vertical Axis

= Voltage/ Amplitude - Size or amplitude of a waveform is measured in millivolts (voltage) or millimeters (amplitude

Horizontal Axis

= time - 1 small square = 0.04 seconds - 1 large square (5 small squares) = 0.20 seconds - 5 large squares = 1 second - 15 large squares = 3 seconds - 30 large squares = 6 seconds

Pleurodesis

A procedure that causes the membranes around the lungs to stick together and prevents the buildup of fluid in the space between the membranes.

Neuro Assessment

A. Level of consciousness (arousal & awareness): best indicator of neuro deterioration (change in LOC): -Conscious -Lethargic: arousable but takes a minute to respond -Stupor: need more stimulation to arouse them. -Coma B. Motor Function: -Spontaneous movement -Localization -Withdrawal -Decortication -Decerebration -Flaccid: pick up their arm drops back to the bed. -Arm drift: hold arms out above them and maintain that function after you hold it up for them. C. Reflexes: -Corneal -Cough -Blink -Gag/swallow D. Pupils: Assess size & response E. Glasgow Coma Scale (GCS) F. Respiratory patterns

Hemodynamic Monitoring

A. Purpose: 1. Identify and treat complex medical problems early 2. Assess for presence of shock, cardiac, and pulmonary abnormalities 3. Evaluate response to treatments B. Noninvasive C. Invasive

Management of Electrical Injuries

A. Special considerations: -Contact points -May have other injuries due to fall or being thrown B. Priorities: -Cardiac monitoring (dysrhythmias, cardiac arrest) -Fluid resuscitation (Parkland formula used) -Neuro assessment (level of consciousness) -Renal management (UOP, signs of myoglobinuria [red or tea colored urine]) -Maintain peripheral circulation (pulses on affected extremities; risk for compartment syndrome - medical emergency [manifestations - decreasing pulses, numbness, tingling, pain on flexion and/or extension]

Hyperkalemia example on ECG

A: K+ (3.5-5.0) Normal B: K+ (6.0-7.0) Elevated T wave C: K+ (7.0-8.0) even higher peaked T wave D: K+ (> 8.0) elevated t wave taller and wider, widened QRS, flat P wave, PRI longer E: K+ (> 10.0) really high T wave and longer, Longer QRS, no P wave

Hypokalemia ECG example

A: K+ (Normal) B: K+ (3.0) T wave depressed C & D: K+ (2.0-3.0) T U wave present E & F: K+ (1.0-2.0) T U present in E , no T wave in F: U present

Dual Chamber

AV sequential pacing.

Uncompensated

Abnormal pH+ one abnormal value (PCO2 or HCO3) -pH: 7.51 -pCO2: 30 -HCO3: 26

Hypovolemic Shock

Acute loss of circulating volume leading to decreased CO. -Causes: Hemorrhage, bleeding, burns, severe vomiting or diarrhea, excessive urination. -Hemodynamics & CMs: Decreased CO, Decreased RAP and PWP, Increased SVR, Decreased SVO2, Hypotension, Tachycardia -Diagnostic procedures: decreased h&h, increased lactate, increased urine specific gravity, changes in electrolytes. -Management/treatment: Airway & breathing first priority Fluid bolus of NS/LR (rapid instillation of 500-1000 mL) Treat underlying cause Passive leg raise (PLR) Vasopressors (pressure may be borderline) Blood loss (do we need to replace it?) FFP, Platelets? Albumin, dextran, Hespan

Acute Respiratory Distress Syndrome (ARDS)

Acute onset (less than 7 days) of refractory hypoxemia and bilateral infiltrates. Causes: -Caused by direct or indirect injury to lungs -Direct injury: Aspiration, chest trauma, pneumonia, pulmonary contusion, inhalation injury, pulmonary embolus -Indirect injury: Sepsis *, shock, pancreatitis, burns, multiple blood transfusions (TRALI), cardiopulmonary bypass, drug/alcohol overdose. Characterized by: 1. Disruption of alveolar-capillary membrane with increased permeability to intravascular fluid 2. Alveoli fill with fluid 3. Dyspnea, hypoxemia refractory to supplemental oxygen 4. Decreased lung compliance and pulmonary infiltrates

Pheochromocytoma

Adrenal Disorder -Rare catecholamine secreting tumor of adrenal medulla. -Excess amounts epinephrine and norepinephrine may cause life threatening hypertension of dysrhythmias, sudden death. CMs: -Tachycardia -Hypertension: Life threatening if > 250/140 -Headaches -Palpitations -Hyperhydroxis -Hypermetabolism -Hyperglycemia

Cushing's Syndrome

Adrenal Disorder Hyperfunction 1. Cushing's syndrome a. Metabolic disorder resulting from chronic, excessive production of cortisol or from administration of glucocorticoids in large doses for several weeks or longer or from ACTH secreting tumor 2. Cushing's disease - abnormally increased secretion of cortisol due to increased amounts of ACTH 3. Secondary causes - excessive secretion of glucocorticoids or excessive secretion of aldosterone Clinical Manifestations: 1. Generalized muscle wasting, and weakness; moon face, buffalo hump; truncal obesity with thin extremities; hirsutism; hyperglycemia, hypernatremia, hypokalemia, hypocalcemia; hypertension, fragile skin Management: 1. Prevent complications with fluid overload, change in immune status, changes in skin integrity, changes in body structure 2. Medications to interfere with ACTH and glucocorticoid production 3. If caused by tumor, radiation, chemotherapy or adrenalectomy (removal of adrenal gland)

Addison's Disease

Adrenal disorders. Hyposecretion 1. Adrenal Cortical Insufficiency a. Addison's disease (Primary adrenal insufficiency) - Hyposecretion (glucocorticoids, mineralocorticoids, and androgen) b.Secondary adrenal insufficiency Hyposecretion of ACTH 2. Addison's crisis a. Life threatening disorder b. Acute adrenal insufficiency c. Caused by stress, infections, trauma, surgery or abrupt withdrawal of exogenous corticosteroid use Clinical Manifestations: 1. Addison's disease (loss glucocorticoids - decreased vascular tone, decreased vascular response to catecholamines, decreased gluconeogenesis); (loss mineralocorticoid aldosterone - dehydration, hypotension, hyponatremia, hyperkalemia) 2. Addison's crisis a. Can cause hyponatremia, hyperkalemia, hypoglycemia, shock b. Severe headache, severe (abd, leg and lower back) pain, generalized weakness, irritability & confusion, severe hypotension

Team Members

Advanced Care Team members: -Paramedics -EMS personnel -Nurses -Doctors -Respiratory Therapist -Pharmacist Advanced Care Team members are skilled in: -BLS (Basic Life Support) -ACLS (Advanced Cardiac Life Support)

Critical Care

Advanced trauma life support guidelines Trauma complications: -Acute respiratory distress syndrome -Sepsis -Shock states -Multiple organ dysfunction syndrome

Automaticity

Allows cardiac cells to generate impulses independently and rhythmically. The heart has several pacemaker cells that generate these impulses. The normal pacemaker, the sinoatrial (SA) node, has an inherent rate of 60 to 100 beats per minute. The atrioventricular (AV) node has an inherent rate of 40 to 60. If the other pacemakers fail, ventricular cells can generate an impulse. They have an inherent rate of 20 to 40. Automatic cells generate an automatic impulse. - Cells can generate without outside stimulation "I can shock back into rhythm."

Traumatic Brain Injury

Any injury or trauma to scalp, skull, meningeal layers, cerebral blood vessels, brain tissue, cranial nerve injury, and neurons. -Classifications: 1. Mild (GCS 13-15) 2. Moderate (GCS 9-12) 3. Severe (GCS 8 or less) -Mechanisms of injury: 1. Rotational forces: Shearing, twisting, diffuse axonal injury, blood vessel dissection 2. Contrecoup (counter-blow): Contusion, swelling, blood clots, epidural and subdural hematomas -Phases of injury: 1. Primary injury: what happens initially at the time of impact 2. Secondary injury: any other injury that occurs after the first trauma

Fractured Ribs

Are considered the most common type that occur of blunt trauma. -Most common ribs 5 through 9 -Can damage pleura and lungs, and surrounding vessels or organs -Clinical manifestations: Pain at the site of injury typically worse with inspiration or coughing, splinting the area, shallow respirations to reduce the amount of pain they are experiencing. -Complications: Atelectasis and pneumonia: over time this can lead to problems with decreased ventilation and retain secretions and develop atelectasis or pneumonia.

Dysrhythmias

Are disruptions in the cardiac conduction pathway or disorders of the electrical impulse conduction within the heart. They can result in deviations from a normal HR and/or rhythm, causing decreases in cardiac output (CO). Some are lethal causing a complete loss of cardiac output which results in cardiopulmonary arrest.

Minimally Invasive Hemodynamic monitoring

Arterial pressure based cardiac output monitoring (APCO) provides a minimally invasive method to measure CO; arterial catheter and monitor permit continuous calculation of CO.

Nursing Management for MI

Assessment: (1) Restlessness (2) Pain (describe characteristics) (3) ECG for changes (4) Lab values - Troponin, CK-MB (5) Vital signs and oxygen saturation (6) Skin color, temperature, peripheral pulses, diaphoresis (7) Urine output (8) Heart sounds, breath sounds Actions: (1) Administer oxygen (2) Start IV access (2 large bore IVs) (3) Administer medications (4) Continuous ECG monitoring (5) Bedrest for 24 hours (6) Elevate the head of the bed (7) Manage client's pain (8) Manage nutrition (NPO initially, progress to low salt, low saturated fat, low cholesterol) Teaching: (1) Signs and symptoms to report immediately (2) Medications (3) Blood pressure target < 120/80 (4) Maintain ideal body weight (5) Heart healthy diet -AHA diet -Reduce fat intake to < 30% total calories/day -Reduce salt intake (6) Total cholesterol < 200; LDL < 100 (7) Keep fasting glucose < 100 (8) Physical activity -monitor heart rate -low-level stress test before discharge (9) Resumption of sexual activity -Discuss when teach about other physical activity -Erectile dysfunction drugs contraindicated with Nitrates -Prophylactic nitrates before sexual activity -Typically, 7-10 days post MI or when can climb two flights of stairs (10) Smoking cessation

Nursing Management for increased ICP

Assessment: -Neuro assessments every 1-2 hours -Vital signs and oxygen saturation every 1-2 hours -Temperature every 1-2 hours -ICP and CPP every 1-2 hours or prn -Manifestations of increased ICP -Cardiac rhythm & markers of myocardial injury -I&O every 1-2 hours -Serum sodium and/or serum osmolality -Serum electrolytes -BUN & creatinine -End-tidal carbon dioxide continuously to guide hyperventilation therapy -Arterial blood gases Actions: -Position HOB >30 degrees, head midline, avoid sharp hip flexion -Avoid position that places pressure directly on operative side after craniectomy -Suction only as needed if intubated and pre-oxygenate before suctioning -Administer sedative medications a prescribed (caution so does not mask subtle changes) -Administer osmotic diuretics and hypertonic saline as prescribed -Ensure continuous drainage of CSF or intermittent drainage as prescribed -Administer antipyretics and/or implement cooling measures -Manage blood pressure and fluid intake: (a) Manage BP based on ICP & CPP [goal MAP at least 70 mmHg, CPP at least 70 mmHg, Systolic pressure 140-150 mmHg] (b) Avoid hypertension - Calcium channel blocker (nicardipine) (c) Avoid hypotension - crystalloids, vasopressors (dopamine) -Perform ICP measurements: (a) Confirm transducer at level of tragus of ear (b) Measure pressure every 1-2 hours (c) Evaluate ICP changes with client's current condition (d) Prevent inaccurate readings -Manage ICP monitoring system (a) Confirm not heparin or preservatives in the fluid, no pressure on fluid (b) Determine if open or closed system (c) Drain CSF as directed by HCP (with ventricular catheter only) (d) Monitor appearance and volume of drainage expect to be pale red color, clear normal, cloudy suspect infection, more concentrated blood notify physician -Avoid activities that may elevate ICP Teaching: -Teach about devices used during hospitalization -Medications -Complications of increased ICP -Rationale for helmet after craniectomy (if used) -Importance of rest (Educate family members)

Nursing Management for Acute respiratory failure

Assessments: -Vital signs and oxygen saturation and PRN RR, HR, BP, T. -Cardiac Monitoring:Dysrhythmias -Neuro assessment: Agitation, somnolence -Breath Sounds: Crackles, rhonchi, diminished or absent Actions: -Administer oxygen (humidified) -Administer medications as ordered -Elevate the head of the bed, mobilize to chair -Turn q 2 hours. If unilateral lung disease, position good lung down (increase perfusion) -Assess need for suctioning, chest physiotherapy -Administer IV fluids for adequate hydration and monitor I&O -Administer nutritional support -Be prepared for intubation and mechanical ventilation. Teaching: -Disorder or disease teaching -Medications -Breathing techniques (pursed lip breathing, diaphragmatic breathing) -Energy conservation -Exercise -Prevention of infection -Diet and adequate hydration -Smoking cessation

Intra-aortic Balloon Pump (IABP)

Assistive device. Goes in through the femoral artery and inflate. a) Placement of balloon in the aorta that inflates during diastole and deflated during systole b) Used to decrease preload, afterload, and coronary artery perfusion resulting in increased cardiac output (CO) c) May be utilized with MI, cardiogenic shock, post CABG

AV node

Atrioventricular node Delays impulse to ventricles; allows for filling. It is a back-up pacemaker if the ventricles don't fire from the SA node. 40 to 60 bpm backup.

CMs and complications of aortic dissection

CMs: 1. Sudden onset severe and persistent pain -tearing or ripping in anterior chest or back, extending to shoulders, epigastric area, or abdomen 2. Blood pressure often markedly different from one extremity to another, often hypotension 3. Diaphoresis, nausea, vomiting, faintness, tachycardia Complications: 1. Aortic rupture - life threatening 2. Hemorrhage 3. Hypovolemic shock 4. Cardiac tamponade 5. Occlusion of arterial supply to vital organs

ARDS Severity

Calculate PaO2/FiO2 ratio daily & trend value need to know how to calculate for the test. -Mild: PaO2/FiO2 (200-300), Mortality (27%) -Moderate: PaO2/FiO2 (100-200), Mortality (32%) -Severe: PaO2/FiO2 (<100), Mortality (45%) *mechanical ventilation of PEEP 5+ or CPAP 5+.

Causes and risk factors of Pulmonary Embolism

Causes: -Thrombus, embolus (DVT) -Tumor particles -Amniotic fluid -Air -Fat (long bone fracture, osteomyelitis, liposuction) Risk Factors: -DVT most common cause or primary risk factor for PE. a)Virchow's triad (venous stasis, vessel wall damage, hypercoagulability) that would increase the risk for developing a DVT. b) Other DVT risk factors: obesity, smoking, chronic heart disease, fracture (hip or leg), hip or knee replacement, major surgery, major trauma, spinal cord injury, h/o DVT, malignancy (could have particles break off and embolize).

Mechanical Ventilator failure

Causes: a. Loss of power to ventilator b. mechanical failure of ventilator Troubleshooting/Interventions: a. Verify plugged into red emergency outlet. Ambu client and contact RT b. Ambu client and notify RT for replacement ventilator.

Respiratory Failure

Combined failures, failure of oxygenation and ventilation. Risk Factors: Impaired Ventilation (hypoventilation): -Airway obstruction -Respiratory muscle weakness/paralysis (neuromuscular diseases i.e. Myasthenia Gravis) -Chest wall injury -Anesthesia -Opioid administration Ventilation-perfusion mismatch: -COPD -Restrictive lung disease (sarcoidosis, pulmonary fibrosis) -Atelectasis -Pulmonary embolus -Pneumothorax -ARDS: respiratory failure can lead to ARDS -Anatomic Shunt Impaired diffusion (alveolar): -Pulmonary edema -ARDS

Tension Pneumothorax

Complication of chest tubes. 1) Accumulation of air or blood in pleural space that does not escape 2)Causes collapse of lung and mediastinal shift toward unaffected side 3) Can result in compression of heart, vena cava, aorta, and unaffected lung one of the hallmark signs would be shifting of the trachea and everything else that collapses it is an immediate response complication can be life threatening. 4) Manifestations: -Tracheal deviation (hallmark sign) to unaffected side -Hemodynamic compromise 5)Medical emergency:Need early detection and relief of pressure 6)Needle decompression or insertion of chest tube

Cardiac Tamponade

Complication of chest tubes. 1) Caused by excessive air, fluid or blood collecting in the pericardial sac 2) Can also be caused by tension pneumothorax 3) Heart cannot fill or contract adequately 4) Manifestations: Hypotension, Muffled heart sounds, Distended neck veins 5) Management:Pericardiocentesis 6) Thoracentesis if due to tension pneumothorax

P wave

Corresponds to atrial depolarization produced by the propagation of the impulse from the SA node through the atria. Atrial Contraction takes place milliseconds after depolarization. - Normally upright (positive), First wave. Represents atrial depolarization -Normally indicates firing of the SA node. Assess for: -Shaped normally? -All P waves similar? -Is there a 1:1 ratio of P's to QRS's -Is there PR interval normal?

QRS complex

Corresponds to ventricular depolarization (fire). Ventricular contraction occurs after the QRS complex in the ST segment. -Depolarization of ventricles a. Q wave: first negative deflection - normal physiologic Q waves (less than 0.04 sec. and less than 1/3 the height of R wave in that lead - Abnormal pathologic Q waves (more than 0.04 sec. and more than 1/3 the height of the following R wave in that lead. Indication of a myocardial infarction. -R wave: first positive deflection after P wave -S wave: first negative deflection after R wave after R wave -QRS normal duration: 0.04-0.10 sec. -QRS variations

T wave

Corresponds to ventricular repolarization. Atrial repolarization occurs during ventricular contraction. The waveform is not visible but is buried in the QRS complex. - Normally upright wave that follows QRS complex Ventricular repolarization (resting): -Follows a QRS complex -Bigger than P wave -Inversion indicates ischemia to myocardium -Normally upright, round, smooth -Abnormal: inverted, peaked, depressed -Peak of T wave is vulnerable period -T wave never shock.

Brain Death

Death: occurs when all vital organs and body systems cease to function, irreversible cessation of cardiovascular, respiratory, and brain function. Brain death: -Utilizes neurologic criteria -Irreversible loss of all brain functions including brainstem -Occurs when cerebral cortex stops functioning or is destroyed -Exact definition of death can be controversial -Procedure to declare patient dead varies by state laws and institutional policies Criteria for brain death: -Coma (unresponsive) -Flaccid extremities -Absent cough, gag, blink reflexes -No spontaneous respirations -Absent oculocephalic reflex (Doll's eye reflex) -Absent, oculovestibular reflex (Caloric reflex test) -Dilated, fixed pupils Testing for brain death: -Apnea test -Transcranial Doppler -Cerebral angiography -EEG hallmark of what we use to determine brain death. -HMPAO SPECT

Ventricular Pacing

Delivers a pulse in the ventricle.

Increased Intracranial Pressure

Described by the Monro-Kellie doctrine. a) 3 components occupy the skull: -Brain tissue (80%) makes up the greatest percentage -Blood (10%) -Cerebrospinal fluid (CSF) (10% b) Hypothesis: to maintain a constant intracranial volume, an increase in any of the 3 components must be accompanied by a decrease in one or both other components, If this does not occur, ICP rises c) Intracranial compliance: -Ability of body to compensate by adjusting levels of Components -Compensation ICP controlled: a. Normal compensatory adaptations, Changes in CSF volume (decreased production or displacement), Changes in intracranial blood volume (displacement), Changes in tissue brain volume b. Ability to compensate is limited: If volume increase continues, ICP rises → Decompensation -Decreased compliance - decreased ability to compensate for increased volume -Loss of compliance - compliance extremely limited and Cerebral herniation syndrome may occur with continued addition of volume. If not resolved, compresses brainstem which will lead to death d) Cerebral herniation syndromes: for whatever the cause is that is an increase in the intracranial pressure. Classified according to region of tissue that is displaces not concerned with knowing all of the names just know that there are different types. -Subfalcine or cingulate herniation -Central herniation -Uncal herniation -Tonsillar herniation

Aortic Aneurysm

Description: 1. Dilatation of the aorta caused by alterations in the integrity of the wall of the aorta; medial layer weakened and other layers stretched Locations: 1. Ascending aorta (may involve aortic valve) 2. Aortic arch 3. Thoracic aorta (TAA) 4. Abdominal aorta (AAA) *most common location Classifications: 1. Fusiform: symmetrical around the wall. A 2. Saccular: sac on the side of the vessel. B 3. Ruptured: where it has clotted off. C 4. Dissection D

Aortic Dissection

Description: 1. Sudden tear in intimal layer of aorta that creates a false lumen 2. Blood enters the false lumen and will cause separation in vascular layers 3. Often misnamed "dissecting aneurysm" but not a type of aneurysm because still have blood flow occurring through the aorta and it is not bulging. 4. May occlude major branches of aorta causing decreased blood supply to brain, abdominal organs, kidneys, spinal cord and/or extremities 5. Classified by location and duration of onset Locations: 1. Ascending and Descending Aorta are the most common location first picture in B 2. Ascending aorta, aortic arch - surgical management second picture in B 3. Descending aorta - medical or surgical management third picture in B

Mechanical Ventilator Modes

Determines how breaths delivered to client. -Based on how much work of breathing (WOB) patient should or can perform -Determined by client's ventilatory status, respiratory drive, & ABGs (assist-control, synchronized intermittent mandatory ventilation, continuous positive airway pressure)

Medical Management of ARDS

Diagnosis: 1) Imaging studies -Serial chest x-rays -Infiltrates 2) Laboratory testing -ABGs -Hypoxemia, hypocapnia (initially) -CBC, sputum, blood and urine cultures -Determine if infectious cause -Comprehensive metabolic panel (CMP), coagulation studies, liver and renal function test -Determine if cause and to assess impact on organs -Pulmonary function tests

Management of Aortic Dissection

Diagnosis: a) 12 lead ECG to rule out MI b) CT scan, Transesophageal echocardiography (TEE) or MRI c) Chest xray Medical Management: a) If no symptoms, may treat conservatively for period of time b) Goal - prevent extension dissection and rupture c) Decrease blood pressure and myocardial contractility: 1) IV beta-adrenergic blocker (Esmolo, Labetalol) 2) Other antihypertensives agents - calcium channel blockers, nitroprusside, ACEIs d) Pain control: Morphine Surgical Management: (repair, resection, reconstruction, replacement) a) Emergency surgery for dissection in abdominal aorta or thoracic aorta b) Endovascular dissection repair (similar to EVAR) c) Repair or resect aorta with graft

Medical Management of peptic ulcers

Diagnostic and lab studies: -Upper GI endoscopy -Noninvasive testing: serum antibody tests, urea breath test (C13 urea breath test), stool antigen test -Other testing: CBC, fecal occult blood, ELISA (immunoglobulin G [IgG] antibodies), ultrasound. Goal of medical management: -Pain relief -Ulcer healing -Prevent ulcer recurrence -Reduction of complications Medications: -Neutralize gastric acids (antacids) -Decreased acid production (H2 receptors antagonists [famotidine, ranitidine]). -Discontinue aspirin and NSAIDs for 4-6 weeks (if must continue use in combo PPI) -Cytoprotective therapy (mucosal protectant): Sucralfate -H pylori infection treatment (antibiotics) -If sedatives used, use mild sedatives (sedatives can mask symptoms of shock). Diet: -NPO, possibly NGT -Avoid dietary irritants (hot foods, spices, alcohol, caffeine, carbonated beverages). -Six small feedings or small hourly meals. -Adequate fluid intake Other management interventions: -Smoking cessation -Adequate rest (physical and emotional) -Stress management -Hydration with IV fluids

Medical Management for valvular disease

Diagnostic tests: 1) ECG (right or left ventricular hypertrophy) 2) Echocardiogram look at the valves and see how they are moving and functioning 3) Chest x-ray 4) CT or nuclear scan to look at the muscle itself. 5) Stress testing what happens when they are active 6) Heart catheterization study the pressures. Medications: 1) Antibiotics - infectious etiology 2) Anticoagulants may be required 3) Antidysrhythmics (Amiodarone) 4)Heart failure management: -Beta blockers -Calcium channel blockers -Diuretics -Inotropes -Vasodilators -Sodium/fluid restriction Aortic Stenosis: require higher preload for blood flow through valve to prevent decreased CO and hypotension.

Torsade De Pointes

ECG Characteristics: -Ventricular Regularity: Irregular -Ventricular Rate: 200-250 beats per minute -P waves: None -PR Interval: None -QRS Duration: Wide (Greater than 0.10 sec), bizarre appearance

Accelerated Idioventricular Rhythm

ECG Characteristics: -Ventricular Regularity: Regular -Ventricular Rate: 41-100 beats per minute -P waves: None -PR Interval:None -QRS Duration: Wide (Greater than 0.10 sec), bizarre appearance

Sinus Arrhythmia

ECG Characteristics: -Ventricular/atrial Regularity: Irregular, varies with respirations between shortest R-R and longest R-R intervals is greater than 0.12 sec. -Ventricular/atrial Rate(s): Usually 60 to 100 beats/min; frequently increases on inspiration and decreased with expiration; may be less than 60 -P waves: Positive (upright) in lead II, one precedes each QRS complex, P waves look alike -PR Interval: 0.12 to 0.20 sec, constant from beat to beat -QRS Duration: 0.04 to 0.10 sec -Rarely affects hemodynamic status: no treatment. Rate varies with respirations: -Inspire= increase -Expire=decrease

Sinus Rhythm

ECG Characteristics: -Ventricular/atrial Regularity: R-R intervals regular, P-P intervals regular -Ventricular/atrial Rate(s): 60 to 100 beats/min -P waves: Positive (upright) in lead II, one precedes each QRS complex, P waves look alike -PR Interval: 0.12 to 0.20 sec, constant from beat to beat -QRS Duration: 0.04 to 0.10 sec

Sinus Tachycardia

ECG Characteristics: -Ventricular/atrial Regularity: R-R intervals regular, P-P intervals regular -Ventricular/atrial Rate(s): Greater than 100 beats/min -P waves: Positive (upright) in lead II, one precedes each QRS complex, P waves look alike -PR Interval: 0.12 to 0.20 sec, constant from beat to beat -QRS Duration: 0.04 to 0.10 sec -Causes: stimulants, exercise, fever, and alterations in fluid status.

Sinus Bradycardia

ECG Characteristics: -Ventricular/atrial Regularity: R-R intervals regular, P-P intervals regular -Ventricular/atrial Rate(s): Less than 60 beats/min. -P waves: Positive (upright) in lead II, one precedes each QRS complex, P waves look alike -PR Interval: 0.12 to 0.20 sec, constant from beat to beat -QRS Duration: 0.04 to 0.10 sec -Causes: increased parasympathetic tone, vagal stimulation drugs, ischemia/MI, ICP and athletes (normal).

Junctional Rhythm ECG

ECG Characteristics: -Ventricular/atrial Regularity: Regular -Ventricular/atrial Rate(s):-40-60 beats per minute -P waves: Absent, Inverted, buried or retrograde -PR Interval: None, short or retrograde -QRS Duration: Usually 0.04 to 0.10 sec

Mild pancreatitis

Edematous or interstitial

Triage

Emergency Severity Index (ESI) [5 level system] Mass Casualty Triage -Emergent or Class I: Red tag, immediate threat to life or limb -Urgent or Class II: Yellow tag, major injuries, needs immediate attention -Non-urgent or Class III: Green tag, minor injuries, no immediate attention -Expectant or Class IV: Black tag, expected or allowed to die

Percutaneous Transluminal Coronary Angioplasty (PCI)

Emergent PCI - treatment of choice for confirmed MI -Goal: < 90 minutes from door to needle/balloon -Balloon angioplasty and stent (may be drug-eluting Intracoronary stents Helps prevent restenosis associated with angioplasty Anticoagulation and antiplatelet after procedure * Cardiac Catheterization care discussed at end of outline

Sever pancreatitis

Endocrine and exocrine dysfunction. After this stage can lead to necrosis, organ failure, sepsis.

Cardiogenic Shock

Failure of the heart to pump blood forward effectively. Causes: -MI -After cardiac surgery -Cardiomyopathy -Valvular disease -Structural changes (papillary muscle rupture, septal defect or rupture) -Ventricular aneurysm -Dysrhythmias -Decompensated end-stage congestive heart failure

Failure to Pace

Failure to fire: Absence of pacing spikes and return of underlying rhythm. -Symptomatic -Assymptomatic Nursing Interventions: 1. Check connections of pacing wire/extension cable attached to pulse generator 2. Check/change pulse generator battery 3. Replace pulse generator unit Remove source of electromagnetic interference 4. Remove source of electromagnetic interference

Undersensing

Failure to sense (overpacing) firing more than it needs to be. -Not sensing client's electrical activity. Results in pacing spikes that occur after or are unrelated to the intrinsic rate. Nuring Interventions: 1. Increase sensitivity setting 2. Replace pulse generator battery Replace or reposition pacing lead

Oversensing

Failure to sense (underpacing). Absence of pacing spikes. Nursing interventions: 1. Decrease sensitivity setting.

PR interval

From the beginning of the P wave to the beginning of the QRS complex reflects the time required for atrial depolarization and the delay of the impulse at the AV node which allows ventricular filling. - Time between the beginning of P wave and beginning of QRS complex - Measures time of impulse travel from atria to the ventricles - 0.12-0.20 seconds -Atrial depolarization/ delay in AV node (allows for ventricular filling). -Shorter interval= impulse from AV junction -Longer interval= First-degree AV block (possible of some type of drug toxicity).

Acute Liver Failure

Fulminant liver failure. -Defined by coagulation abnormality & encephalopathy without previous liver disease. Causes: -Acetaminophen overdose -Other medications, herbal supplements -Viruses -Hepatitis -Autoimmune disorders -Shock (hypoperfusion) -Toxic ingestion, inhalation, or topical exposure to chemicals and poisons including wild mushrooms -Liver trauma (blunt or penetrating)

Kidney Transplant

General Info: -one or both kidneys (if donor deceased) -only one kidney if donor deceased -may be transplanted in combo with pancreas transplant Indications: -glomerular diseases -diabetes -polycystic kidneys -hypertensive nephrosclerosis -tubular & interstitial dis -neoplasms -graft failure a. Postoperative care -Live donor: 1. Care similar to open or laparoscopic nephrectomy 2. Close monitoring of renal function 3. Close monitoring of hematocrit -Recipient: 1.First Priority - maintenance of fluid and electrolyte balance 2. Large volumes of urine soon after transplanted kidney placed 3. Urine output replaces with fluids milliliter by milliliter hourly 4. Acute tubular necrosis can occur and may require dialysis 5. Maintain urinary catheter patency 6. Diet: -May resume more normal diet -No protein restriction -Sodium restriction (steroids) -Low fat -Low cholesterol Client education: 1. Medications 2. Home assessment - temperature, BP, HR 3. Incision care 4. Prevention of infection 5. When to call HCP 6. Follow-up with HCP

Heart transplant

General info: -most transplants replace heart with heart from cadaver donor (leave portion of atria) - Sometimes patient's heart not removed (heterotopic transplant) Indications: -cardiomyopathy -refractory end stage HF -CAD (inoperable) -congenital heart disease -valvular disease -graft failure Other info: -Endomyocardial biopsy to detect rejection. a. Postoperative management: -High resting heart rate -Bradycardia may require temporary pacing or isoproterenol -Supraventricular tachycardia - manage with beta blocker, calcium channel blocker -Assessment - will not experience chest pain - teach client to report declining exercise tolerance -Monitor for complications: 1. Ventricular failure 2. Bleeding 3. Graft rejection: Detect with Endomyocardial biopsy: -Obtained from right ventricle -Frequency - weekly for first month, monthly for next 6 months, yearly thereafter 4. Infection: Client education: 1. Medications 2. Home assessment - temperature, BP, HR 3. Incision care 4. Prevention of infection 5. When to call HCP 6. Follow-up with HCP

Medications for Pulmonary Hypertension

Goal to slow the progression of the disease. a) Prostacyclins therapy - blood vessel relaxation 1) Treprostinil (Remodulin) - SQ or continuous IV infusion 2) Epoprostenol (Veletri) - continuous IV infusion 3) Iloprost (Ventavis) & Treprostinil (Tyvaso) - intermittent inhalation treatments b) PDE-5 inhibitors (Phosphodiesterase inhibitors) *Sildenafil (Revatio) and tadalafil (Adcirca) - oral agents *Viagra causes vasodilation. c) Endothelin receptor antagonists - blocks vasoconstriction Bosentan (Tracleer) and ambrisentan (Letairis) d) Calcium Channel blockers e) Vasodilators (IV or inhaled) f) Anticoagulants might be used for longterm to prevent PE. g) Diuretics prevent ascites that might occur. h) Oxygen to prevent further vasoconstriction in addition to the low oxygen levels.

ARDS criteria

Have to have these in order to classify for this. 1. Refractory hypoxemia 2. P/F ratio<300 mmHg 3. Bilateral infiltrates on chest x-ray

Impaired Ventilation

Hypercapnic respiratory failure (Failure of ventilation): Type II -Respiratory acidosis -pH<7.35 -PaCO2>50 mmHg -Hypoxemia may or may not be present.

Impaired Gas Exchange

Hypoxemic respiratory failure (failure of oxygenation): Type I not adequately oxygenating. -PAO2 <60 mmHg despite increased inspired oxygen -Normal or low PaCO2

Aneurysmectomy/Open aneurysm repair (OAR)

If aneurysm extends above renal arteries or if cross-clamp above renal arteries: -Check for adequate renal perfusion and monitor for postop renal complications make sure they are adequately hydrated.

Management Superventricular tachycardia

If patient is symptomatic: -Vagal stimulation -Adenosine: slows down heart rate. -Amiodarone -Verapamil -Dilitazem -Cardioversion -Ablation

Management of third degree AV block

If the patient is symptomatic because of the slow heart rate: -Apply a pulse oximeter -Administer supplemental oxygen, if indicated -Establish IV access and obtain a 12-lead ECG -Medications: IV atropine may be tried, Epinephrine, dopamine, or isoproterenol IV infusions -Temporary or permanent pacing may be necessary -Frequent patient reassessment is essential

Management of Junctional rhythms

If the patient's signs and symptoms are related to the slow heart rate: - Apply a pulse oximeter - Administer supplemental oxygen, if indicated - Establish intravenous (IV) access - Obtain a 12-lead ECG - Administer IV atropine - Reassess the patient and continue monitoring

CPR Adult

If the victim has a pulse: -Open airway -Give 1 breath every 5-6 second -10-12 breaths a minute -Deliver each breath over 1 second -Recheck pulse every 2 minutes or 5 cycle of CPR If the victim does not have a pulse: -Start compressions in center of chest at the nipple line -Use the heel of one hand on top of the other -Ratio 30:2 ratio ***with an advanced airway in place, ventilations are asynchronous -Compression at least 100-120 per minute -Allow recoil of chest -Depth of at least 2 inches but not >2.4 inches -Reassess after 5 cycles or 2 minutes -Rotate compressors every 2 minutes

Transplant medications

Immunosuppressants: 1. Must take for life, at risk for toxicity the rest of life 2. Corticosteroids - methylprednisolone, prednisone 3. Monoclonal antibodies - Muromonab-CD3 (OKT3), dadizuman 4. Polyclonal antibodies - Atgam 5. Antithrombocyte globulin - thymoglobulin (ATG) Adjunct medications: 1. Antibiotics 2. Antifungals 3. Anti-ulcer 4. Diuretics 5. Antivirals 6. Statins 7. Vaccines

Pericarditis

Inflammation of the outer lining of the heart or the outer coating of the heart.

Location Pulmonary Artery Catheters

Inserted through subclavian, internal or external jugular (avoid if possible can cause infection or contamination), or femoral vein (emergency situation), -Don't use distal for IV fluids. Just use for pressures. -Proximal use for RAP, IV fluids, sample blood IV meds.

Nursing management for smoke inhalation

Interventions: Assessment: -Assess facial/neck for burns, singed nasal and/or facial hairs -Visual inspection of upper airway -Vital signs -Breath sounds and respiratory rate -Changes in voice, hoarseness, and/or difficuly swallowing -Oxygen saturation, arterial blood gases, carboxyhemoglobin levels Actions: -Administer 100% humidified oxygen -Trend ABGs and carboxyhemoglobin -Elevate the head of bed -Prepare for emergecy intubation -Monitor mechanical ventilation and for signs respiratory distress Teaching: -Report difficulty breathing or swallowing immediately -Cough and deep breathe every hour -Signs of inhalation injury

Nursing Management of GBS

Interventions: Assessment: -Cranial nerves VII, IX, X, XI, and XII -Respiratory assessment with vital capacity measurement -Motor and sensory assessment -Pain assessment Actions: -Reposition/turn frequently -Pain management (may use carbamazepine or gabapentin to relieve neuropathic pain) -Offer diversions -Range of motion once a shift -VTE prophylaxis -Establish communication method Teaching: -Educate client and family about GBS -Teach importance of respiratory monitoring in acute phase -Inform of resources

Nursing Management of Traumatic Brain Injury

Interventions: Assessment: -Airway assessment -Neuro assessments every 1 - 2 hours in acute phase injury (LOC, GCS), reflexes & cranial nerves -ECG and cardiac biomarkers to make sure that there is no other damage. -Vital signs (BP, HR, R, temperature, ICP, CPP) -Seizure activity -CSF leak (verify CSF - glucose or halo test) -Bruising (periorbital ecchymosis and edema, Battle's sign) Actions: -Position client HOB > 30 degrees with head midline, avoid sharp hip flexion -Management of CSF leak: Elevate HOB, Loose collection pad, No sneezing or blowing nose because that could increase the leak or at more risk for infection, NO NG tube, NO nasotracheal suctioning -Avoid NGT in clients with basilar skull fracture (use orogastric tube alternative) -No nasotracheal suctioning -Monitor ICP, CPP and implement interventions to control: Manage nausea and vomiting - antiemetics -Initiate enteral nutrition within first 72 hours -Manage eye problems: Eye drops, compresses, patch -Maintain normothermic temperature: Target 36 - 37 degrees Centigrade, prevent shivering, antipyretics, cooling devices -Implement seizure precautions: suction setup, prevent with antiseizure medications (levetiracetam [Keppra], phenytoin Dilantin)), stop seizure activity with medication (lorazepam [Ativan]) -Ensure VTE prophylaxis and GI prophylaxis Teaching: -Injury, coma and increased ICP: Educate patient and family about post- concussive syndrome (headaches, difficulty concentrating, dizziness, fatigue, irritability, sleep disturbances) -Orientation to client's room and equipment -Signs and symptoms of complications -Have someone stay with the client -Abstain from alcohol -Avoid driving, using heavy machinery, playing contact sports, taking hot bath for time prescribed -Acute rehabilitation: depending on the area affected in the brain will involve these different types of rehab: Motor and sensory deficits, Communication issues, Memory and intellectual functioning, Nutrition, Bowel and bladder management -Seizure disorders -Mental and emotional difficulties -Progressive recovery -Family participation and education -Preventive measure for TBI: prevent car and motorcycle accidents, wear safety helmets, use seat belts and child car seats, home safety to prevent falls.

Nursing Management for GI bleeding

Interventions: Assessment: -Emergency assessment: assess if actively bleeding (life threatening), assess airway, breathing, circulation (vital signs) -Assess if hemodynamically unstable and need for resuscitation. -ECG rhythm -Stools for blood, recurrence of bleeding -Nausea and vomiting bright red blood will require immediate action instead of coffee ground through vomiting. -Delirium tremens if bleeding related to chronic alcohol abuse (agitation, uncontrolled shaking, sweating, hallucinations). Actions: a. Emergency Actions: -Monitor vital signs every 15-30 minutes -Manage arterial pressure lines and central venous accesses obtaining pressures at least hourly -Insert at least two large bore IV catheters and begin fluid resuscitation (crystalloids) to keep MAP 60 mmHg -Monitor Hct, Hgb, clotting studies, type and cross for RBCs -Administer IV fluids, colloids and blood products as ordered until stabilized -Monitor fluid balance and renal function (I&O, daily weight, BUN, creatinine and hourly urine output) -Use caution when administering sedatives for restlessness b. Monitor NGT (if present) c. Maintain proper placement d. Observe aspirate for blood e. NPO initially, then feed clear fluids hourly f. Gradual introduction of food as tolerated g. Administer prescribed medications h. Prepare for endoscopy: -Administer prokinetic agents (erythromycin or metoclopramide)- facilitate gastric emptying of retained blood -Administer sedation (midazolam) -Monitor for cardiac ischemia during procedure -Control or stop bleeding -Epinephrine injection into ulcer -Sclerotherapy -Thermal methods -Band ligation (varices) Esophagogastric (balloon) tamponade: a. Sengstaken-Blakemore tube b. Balloon inflated with air c. Compress proximal gastric veins, varices d. Reduce esophageal blood flow e.Nursing Actions: -Connect esophageal balloon to manometer -Inflate to 20-45 mm Hg -Secure tube to avoid dislodging -Tape to face guard or helmet -Deflate q8h for 15 min. -Have scissors at bedside to deflate in event of respiratory distress -Monitor for complications: pulmonary aspiration, Respiratory distress Teaching: -How to avoid future bleeding episodes -Teach consequences of noncompliance with diet and drug therapy -Emphasize that no drugs other than those prescribed should be taken -No smoking or alcohol -Need for long-term follow-up care -Instruction if an acute hemorrhage occurs in future -Disease process and drug therapy -Avoidance of gastric irritants -Alcohol, Smoking, Stress-inducing situations -Take only prescribed medications -Testing emesis/stools for blood -Prompt treatment of upper respiratory infection in patient with esophageal varices -If aspirin must be prescribed, enteric-coated tablets can be substituted for regular tablets -Taking the medications with meals or snacks lessens the potential irritating effects

ST-elevation Myocardial Infarction

Is a complete occlusion of a major coronary vessel resulting in irreversible full thickness heart muscle damage.

Cardioversion

Is a medical procedure that restores a normal heart rhythm in people with certain types of abnormal heartbeats (arrhythmias). Is usually done by sending electric shocks to your heart through electrodes placed on your chest. It's also possible to do with medications. (Synchronized) used on A fib. or rapid ventricular response rate. -Key points -Procedure -Nursing responsibilities

Non ST-elevation myocardial infarction

Is a partial occlusion of a major coronary vessel or complete occlusion of a minor coronary vessel causing reversible partial thickness heart muscle damage.

Excitability

Is the ability to respond to a stimulus and generate an impulse. All cells in the heart have this property.

Medical Management of Cardiogenic Shock

Laboratory and diagnostic testing: -Cardiac enzymes, 12 Lead ECG - MI related -ABG, mixed venous saturation -Lactate level Medications: Goals - decrease preload, decrease afterload, increase CO/CI, increase contractility -Inotropic meds - Dobutamine, epinephrine -Vasopressors - dopamine, norepinephrine, or phenylephrine -Nitroglycerin -Nitroprusside -Beta-blockers -Diuretics -Analgesics - Morphine -Antidysrhythmics Treatment: -Oxygenation & ventilatory support -Early revascularization

Complications of arterial catheter

Main functions as nurse is to watch for these complications when these materials are in place. 1. Hemorrhage 2. Infection 3. Damage or occlusion of artery 4. Thrombus formation and/or emboli 5. Neurovascular impairment 6. User error (inaccurate readings)

Sinus Tachycardia assessment and management

Management: -Assess client tolerance of tachycardia -Assess for low cardiac output manifestations: Change LOC, chest pain, hypotension, SOB, respiratory distress, dizziness/syncope, fatigue, restlessness -Identify the cause and treat cause: Fever, anemia, hypotension, pulmonary embolism and MI, stimulants alteration in fluid status Examples: Pain give pain medication Fever give antipyretic

Arterial Pressure

Mean arterial pressure (MAP), is the average pressure in a patient's arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure.

Peak Inspiratory Pressure (PIP)

Measurement of client/ventilator produced data. -Amount of pressure it takes for ventilator to deliver tidal volume or breath -Should be less than 40 mmHg.

Minute Ventilation

Measurement of client/ventilator produced data. -Amount of gas moved in and out of lung per minute. -RR x TV= MV normal 5-8 L/min. -12 bpm x .600 or (600 TV)= 7.2 L/min.

Exhaled Tital Volume (EVt)

Measurement of client/ventilator produced data. -Should not be more than 50 mL difference from the set ventilation.

Mechanical ventilator

Mechanical device designed to provide all or part of the work of the body to move gas in and out of the lungs.

Physiology of the Heart

Mechanical physiology: -Systole: the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries. -Diastole: the phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood.

Compensation

Mechanisms that normalize the pH when there is acid-base imbalance a) Kidneys compensate for respiratory abnormality (CO2) b) Lungs compensate for metabolic abnormality (excrete H+ or retain HCO3) -Uncompensated -partial compensation -full compensation

Nursing Actions for CV surgery

Maintain Ventilation and Oxygenation: 1) Intubation and ventilator, wean/extubate 2-6 hours after surgery, supplemental oxygen for 1-2 days 2) Collaborate with respiratory therapy 3) Monitor SaO2 and SVO2 to help with weaning process. 4) Pulmonary interventions - cough and deep breath after extubation, incentive spirometry, early mobilization (OOB in chair within 12-24 hours), DVT prophylaxis, daily chest x-ray 5) Complications to look for: Prevent atelectasis, pneumonia, pulmonary edema, respiratory insufficiency Prevent/detect bleeding from vascular graft anastomosis sites: 1) Assess incision site/dressing for bleeding 2) Monitor mediastinal/pleural tube drainage at least every hour: -Too much drainage - greater than 150 ML/hr for 2 consecutive hours call HCP, Management: administer platelets, RBCs, FFP, protamine sulfate, avoid hypertension -Sudden decrease or absence of drainage Management: Assess for cardiac tamponade & notify HCP; monitor Hct and coagulation status, avoid periods of hypertension Prevent/manage cardiac tamponade: 1) Assess frequently for signs and symptoms: tachycardia, shortness of breath, anxiety, decreased LOC, pulsus paradoxus, sinus tachycardia, decreased mediastinal tube drainage, increased RAP/PAD, decreased BP, muffled heart sounds except for immediately after surgery after surgery it could be there but way after surgery it should not be there which could indicate cardiac tamponade, decreased CO 2) Assess closely for s & s after removal of epicardial wires Monitor for cardiac dysrhythmia can occur at anytime, recurrent ischemia or infarction: 1) ECG monitoring, 12 lead ECGs, ST segment monitoring 2) Assess serial troponin, CKMB levels 3)Treat unstable rhythms, maintain K+ and Mg++ within normal limits, pacing with epicardia wires as needed. Manage pain and anxiety: 1) Administer analgesics (morphine, nitrates) and anxiolytics 2) Pre-medicate to facilitate activity and C&DB Minimize potential for heart failure: 1) Minimize myocardial O2 consumption with betablockers, limited physical activity, avoid increased in metabolic rate (fever) 2) Reduce afterload with ACEI and hydralazine Prevent fluid and electrolyte imbalance and acute kidney injury: 1)Foley with hourly urine output, I&O 2)Daily weights 3)Electrolytes, renal function - replace as needed 4)Tight glycemic control with insulin drip/accucheks Prevent/detect stroke: 1) Assess for cerebral ischemia/stroke 2) Assess level of consciousness, neuro assessment Prevent/detect cardiogenic shock. Prevent infections: 1) Prophylactic antibiotic for 24 hours 2) Temperature spike within first 24 hours not abnormal 3) Incision(s) care after dressing removed incision is usually covered up until 24 hrs. 4) Oral care every 2 hrs when they are intubated, removal of foley within 24-48 hours, management invasive lines

Medical Management of Pulmonary Embolism

Medications: - Anticoagulants depending on how large these emboli are they could be placed on: a) Heparin IV drip or subcutaneous low molecular weight heparin, fondaparinux, or unfractionated heparin b) Continue oral anticoagulants after discharge with Coumadin to continue the anticoagulation. The goal with anticoagulation is to prevent the clots from increasing in size and to prevent new clots from forming so it really doesn't break down the clot but hopefully will prevent the increase in size and number of clots. -Thrombolytics (if hemodynamically unstable) this might be done in radiology if the patient is hemodynamically unstable if (1) they have had a massive pulmonary embolus they may go in and try to resolve that clot. -Vasoactive agents (hemodynamic instability): if they remain unstable may have to use these to try and stabilize them if we had to then we might have to use vasoconstrictors to try and support their blood pressure and in some cases even use dobutamine to try and improve their ventricular function. -Isotonic IV fluids: so that we don't cause any additional fluid accumulation so normal saline or lactated ringers are the ones that are most frequently utilized. -Inotropes - dobutamine if to overcome PVR

Minimally Invasive Pacemaker

Micra transcatheter pacing system.

Endovascular aneurysm repair (EVAR)

Minimally invasive. Complications of EVAR: -Endoleak (leak), aneurysm growth, aneurysm growth, aortic dissection, bleeding, stent migration, renal artery occlusion, graft thrombosis (pressure accurate or could clot off), incisional site hematoma, site infection

Valve Replacement

Most aggressive management with either one of these any development of murmur is not good. -Mechanical -Biologic

Positive Pressure Ventilation (PPV)

Movement of gas into lungs through positive pressure: -Used primarily for acutely ill adults. -Delivers air into lungs under positive pressure during inspiration which leads to intrathoracic pressure increases during lung inflation (opposite of normal) -Expiration occurs passively.

Stenosis

Narrowed opening where it can't open completely

Complications of acute pancreatitis

Necrotizing pancreatitis: -Caused by activation of pancreatic enzymes that "eat through the tissue" and enters the peritoneal cavity and damages the surrounding tissue leading to inflammation and hemorrhage from rupture of blood vessels -At risk for sepsis, shock, multiple organ failures -Treatment: drainage or debridement of necrotic tissue, or pancreatic resection. Pancreatic hemorrhage: -CMs: increased pain, decrease BP, increased HR, cullen's or grey turner's signs -Treatment: embolization to stop hemorrhage. Pancreatic pseudocyst: -Encapsulated areas of fluid that contain pancreatic enzymes and pancreatic tissue. -Form 4-6 weeks after episode pancreatitis -If becomes infected, pancreatic abscess: CMs chills, fever, nausea, vomiting and abdominal pain. -Treatment: percutaneous drainage or removal necrotic tissue and drain fluid. Systemic Complications: -Pulmonary edema, pleural effusion, atelectasis, pneumonia, ARDS -Cardiogenic shock, hypovolemic shock -Hypocalcemia (tetany) -Altered glucose metabolism -Metabolic acidosis -Infection -Renal failure -GI bleeding

Nursing Management of PE

Nursing Interventions: Assessment: -Chest pain can have a sudden onset of this pain along with that they generally have dyspnea and tachypnea those are usually the first three signs. If it is large enough of a PE. -Oxygenation would use pulse oximetry for these patients. Decreases from baseline are usually a result from the dead space ventilation part of that blood flow through the lungs is not able to participate in the gas exchange so more blood is being returned unoxygenated. -Vital signs monitor for tachycardia most likely related to that hypoxemia, they could have a decrease in blood pressure and that's more likely with the massive PE where they are hemodynamically unstable and having a problem with the left and right side of the heart. Their tachypnea could be related to the decrease in oxygen level and could also be related to the pain that they are experiencing. Over time may also develop inflammation and may present with a fever. -ABGs (initial) as it progresses they will have tachypnea and that would lead to respiratory alkalosis, they would also have hypoxemia because of that dead space ventilation as they progress they are going to wind up switching the anaerobic metabolism to they are more likely to result in their gases to result in metabolic acidosis and transition to that anaerobic metabolism as a result of hypoxia. -Lactic acid levels (increased with anaerobic metabolism)that would help confirm that they are doing anaerobic lab values. -Coagulation studies: PT, and INR tests -Urine output: want to monitor as an early sign of evidence of shock where we are poorly perfusing the kidneys and the urine output drops. Rather than use 30 ml per hour as a guide we like to fine tune it and use 0.5 ml/kg/hr as being the normal range we are trying to target.

Acute Respiratory Failure

One or both of gas exchange functions of lungs compromised (inadequate gas exchange) 1. Insufficient O2 transferred to the blood: hypoxemia PaO2 <60 mmHg 2. Inadequate CO2 removal: hypercapnia PaCO2 >45 mmHg Classifications: 1. Impaired gas exchange 2. Impaired ventilation

Failure to Capture

Pacemaker spikes not followed by P waves (if electrode in atrium) or QRS complexes (if electrode in ventricle). Nursing interventions: 1. Reposition client to left side 2. Increase the output setting (mA) until capture occurs

CMs of pancreatitis

Pancreatic Inflammtion -Acute pain: may radiate to back of shoulder, more intense after eating high fat content food, constant & severe, lying or bending forward may aggravate, associated with nausea, vomiting, anorexia. -Abdominal fullness -Hiccups -Indigestion -Fever -Tachycardia -Hypotension -Fluid volume deficit: hypotension, tachycardia, mental status changes (restlessness, mild confusion), cool, clammy skin, decreased urine output. -Impaired gas exchange: could have hypoxemic respiratory failure development. PaO2<60%, SaO2<90%.

Body Surface Area

Patient height and weight.

Extent of Burns

Percentage total body surface area percentage (%TBSA): a. Methods for estimating -Rule of palm: Hand and fingers 1% of TBSA -*Rule of nines: Body divided into surface areas of 9% Used for quick triage (useful prehospital). Head and neck 9% Anterior trunk 18% Posterior trunk 18% Arms 9% (each arm) Legs 18% (each leg) Perineum 1% 2. Severity of burn: a. Factors: Inhalation injury, client age, past medical history, presence of other injuries b. Face, neck, chest → respiratory obstruction c. Hands, feet, joints, eyes → self-care d. Ears, nose, buttocks, perineum → infection e. Circumferential burns f. Compartment syndrome

Internal Pacemaker

Permanent: totally implanted, cannot have an MRI not compatible.

Liver Biopsy pre-procedure, post procedure care

Pre-procedure: -Written consent -NPO at least 6 hours before procedure -May receive a sedative prior to procedure Post procedure care: -Position on right side for 2 hours that's trying to splint that area to prevent bleeding. -Bedrest for 6-8 hours -Leave dressing on until next day -Avoid strenuous activity several days up to a week or longer; not cough hard or strain for several hours after procedure -Site tender/sore for several days, pain med as prescribed (no Aspirin) -Patient education - Notify HCP for fever, chills, redness, swelling, bleeding, increased pain, shortness of breath or difficulty breathing.

Nursing management for aortic dissection

Preoperative management: 1) Position in semifowler's 2)Maintain calm, quiet environment 3)Manage blood pressure with titrated and/or intermittent antihypertensives 4) Manage pain and anxiety with prescribed medications (opioids, antianxiety meds) (pain raises blood pressure which could lead to rupture of dissection) 5)Monitor ECG rhythm and rate 6) Manage intra-arterial pressure monitoring 7) Assess for changes peripheral pulses 8) Assess vital signs frequently (q15 min) Postoperative management: 1) See aneurysm postop care - control BP and pain Teaching: 1)Medications - antihypertensives 2) If pain returns or symptoms progress (*pain, parasthesias, paralysis, pulselessness, pallor), instruct client to seek immediate help

Central Venous Access Devices (CVADs)

Prevent from having infections. 1. Peripheral - Peripherally inserted central catheter (PICC) 2. Nontunneled or percutaneous - common sites - internal jugular (IJ), subclavian (SC), femoral (in emergencies only) 3. Tunneled - Hickman, Broviac, Groshong 4. Implanted - Port-a-cath

Phases of trauma care

Prevention: -Prevent unintentional injury -Risk, recognition, treatment of intimate partner violence Pre-hospital Care: -Triage if multiple casualties -Resuscitation (if needed) -Priorities: Immediate stabilization and transportation: a. Assess airway with cervical spine immobilization (if needed) b. Control external bleeding and shock c. Immediate transport (ground or air)

Causes of Pulmonary Hypertension

Primary Pulmonary Hypertension (PPH): -No lung disorder -Cause unknown or idiopathic Secondary pulmonary hypertension: -Due to another medical condition -Connective tissue disease, congenital heart disease, liver disease, HIV, pulmonary infection that produced fibrosis.

Mechanical ventilation

Process by which air is moved into and out of lungs by a mechanical ventilator.

Pulmonary artery Catheters

Pulmonary artery pressures. Measures the pressures within the lungs itself and those vessels. Flexible, balloon tipped catheter inserted through right side of heart into pulmonary artery. -Lumens: distal, proximal, thermistor (picks up temperature), and inflation lumen (some have additional lumens).

Emergency Medications

Pulseless arrest, asystole: Epinephrine: • Increases HR, peripheral resistance, coronary perfusion pressure • Cardiac arrest Vasopressin: • No advantage found over epinephrine and has been removed from the ACLS algorithm (may still used) • Peripheral vasoconstriction: Can be used as an alternate to epinephrine in asystole or PEA • Cardiac arrest: 40 units IV/IO push (one dose only) • Vasodilatory shock: Continuous infusion, 0.02 to 0.04 units per minute Dopamine: -Hypotension -Symptomatic bradycardia (if Atropine not effective) -Inotropic effect/Increase BP & CO -Correct hypovolemia before use -Can cause tachyarrhythmias -Titrate up to 20mcg/kg/min max Dobutamine: -Increase myocardial contractility without raising oxygen demand -Titrate up to 20 mcg/kg/min -Titrate so that HR does not > 10% baseline -Severe cardiogenic shock or hemodynamically significant hypotension: 0.1 to 0.5 mcg/kg per min, Mix 4 mg to 8 mg in 250ml of D5W or D5NS, but not NS alone -Will increase myocardial oxygen requirement Norepinephrine: -Severe cardiogenic shock or hemodynamically significant hypotension: 0.1 to 0.5 mcg/kg per min, Mix 4 mg to 8 mg in 250ml of D5W or D5NS, but not NS alone, Will increase myocardial oxygen requirements • Pulseless ventricular rhythms: Antiarrhythmic medications: -Amiodarone: Prolongs refractory period & action potential, Cardiac arrest: (300mg IV/IO push (diluted in 20-30ml D5W) Can be followed with 150mg IVP bolus in 3-5 minutes) • Recurrent ventricular fibrillation or unstable v-tachycardia: 150 mg IV/IO over first 10 minutes, may repeat every 10 minutes, Continuous drip: (1mg/min for 6hrs, then 0.5mg/min) • Note: Amiodarone & Lidocaine are used for shock refractory VF or VT • May be used for some atrial arrhythmias • Complications: Hypotension with rapid infusion, Prolongs the QT interval Lidocaine: • Depresses automaticity & conduction of PVCs • Ventricular fibrillation or pulseless ventricular tachycardia • Stable wide complex tachycardia • IV bolus: 1mg to 1.5 mg/kg • Continuous drip 1-4 mg/min Symptomatic Bradycardia: Atropine: -Increases HR/Accelerates AV conduction -Symptomatic bradycardia -0.5mg q 3-5 minutes as needed IVP -Maximum of 3 mg Narrow Complex SVT: Adenosine: -Slows conduction thru AV node -Stable narrow complex PSVT -Position patient in slight reverse Trendelenberg -6 mg RAPID IVP (follow with 20 ml flush) (then 12mg, then 12mg again) -Elevate extremity if given peripheral Pulseless Electrical Activity (PEA): -The H's: Hypoxia, hydrogen ion (acidosis), hyper or hypokalemia, hypothermia, hyper or hypoglycemia -The T's: Toxins, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary), thrombosis (coronary), trauma

Manage Hepatic Encephalopathy

Reduce bacterial ammonia formation: -Cleansing enemas, cathartics -Lactulose (Cephulac), which traps ammonia in gut -Rifaximin (Xifaxan), Neomycin antibiotics -Prevent constipation Monitor ammonia levels: -Treatment of precipitating cause: Control GI bleeding -Remove blood from GI tract

Arrhythmias

Refers to any change from the normal sequence of electrical impulses. The electrical impulses may happen too fast, too slowly, or erratically causing the heart to beat too fast, too slowly, or erratically. When the heart doesn't beat properly, it can't pump blood effectively. When the heart doesn't pump blood effectively, the lungs, brain and all other organs can't work properly and may shut down or be damaged. -Grouped by Anatomical areas: SA node, Atria, AV Bundle (AV node, Bundle of His), Ventricles (Purkinje fibers)

QT interval

Reflects the time required for ventricular depolarization and repolarization. - Measured from beginning of QRS to the end of T wave. - Represents total ventricular activity. -0.39 to 0.43 second -Varies heart rate -Prolonged can predispose to development of torsades de pointes (ventricular tachycardia) -Prolonged can be intensified by hypocalcemia, hypomagnesemia.

QRS interval

Reflects the time required for ventricular depolarization. Beginning of the Q wave to the end of S wave. -Ventricular depolarization -0.06 to 0.12 sec. -Wide: slowed conduction (lethal): Bundle branch block (BBB), ventricular rhythm Assess about QRS: - Is there a QRS for every P wave? - Is the R-R interval regular? - Is there a normal duration?

Cardiac Cells

Relay almost exclusively on aerobic metabolism for adenosine triphosphate production. Without the production of lactic acid that occurs with anaerobic metabolism, cardiac muscle can maintain its regular lifelong rhythm without tiring. They also sustain a longer contraction, allowing ejection of blood from the atria and ventricles. They also have a longer absolute refractory period, decreasing the possibility of repetitive, uncontrolled muscular contractions called tetany.

Cardiac Muscle

Relies on extracellular calcium to facilitate calcium release from the sarcoplasmic reticulum to produce its muscular contraction. This is referred to as calcium-induced calcium release. It is regulated by the slow inward flow of the positively charged calcium ions during the action potential.

U wave

Represents purkinje fiber repolarization and is rarely seen. However, this waveform can be seen in patients with certain drug toxicities (ex. digoxin toxicity) and electrolyte imbalances (ex. hypokalemia). When it is seen, it should be small rounded wave in lead 2 be careful not to confuse with P wave. -Repolarization of His-Purkinje -Normal in children but represents hyperthyroidism or hypokalemia in adults

Cardiopulmonary Bypass

Requires sternotomy, excision of pericardial sac, myocardial preservation (cardioplegia), cardiopulmonary bypass. 1) Functions: oxygenation, mechanical circulation 2) Requires: anticoagulation, Hemodilution 3) Complications: bleeding, anemia, fluid & electrolyte imbalances, hypothermia, infection

Emergency Department Care

Resuscitation phase: -Hypovolemic shock -Two large-bore peripheral IV lines -Place urinary and gastric catheters Primary survey: ABCDE - Airway - Breathing - Circulation - Disability - Exposure -Purpose - identify life threatening conditions and institute management -Airway maintenance with cervical spine protection and/or immobilization 1.Airway patency: Head tilt, chin lift (if no trauma), Modified jaw thrust (if trauma suspected - cervical spine stabilization) -Look, listen, feel for air movement -Teeth, emesis, blood clots, foreign body -Auscultation of breath sounds 2. Breathing and ventilation -Assessment: Chest wall integrity, Respiratory rate, depth, and symmetry -Management: Oxygen, Bag-valve-mask, mouth to mask ventilation, Endotracheal intubation, Chest tube placement 3.Circulation with hemorrhage control: -Assessment:Heart rate, blood pressure, central & peripheral pulses, External bleeding, Level of consciousness -Management: Direct pressure to stop bleeding, Advanced Cardiac Life Support (ACLS), Insert 2 large bore IV's for fluid resuscitation 4. Disability: neurological status: -Assessment: Rapid neurological assessment, Level of consciousness, Pupil size, shape and reaction 5. Exposure or environmental control: -Assessment: All clothing removed for thorough examination -Management: Warm blankets, IV fluids, ambient temperature Secondary survey: FGHI - Full, Focused, Facilitate - Give Comfort Measures - History & Head to Toe - Inspect Posterior Surfaces Purpose - identify other injuries not detected with primary survey including comorbidities Full vital signs, Focused adjuncts, Facilitate family presence -Full vital signs -Focused adjuncts: ECG, pulse oximetry, end-tidal CO2 monitoring, Indwelling catheter, OGT/NGT, Determine need for tetanus injection, Labs & Diagnostics -Facilitate family present: Presence during resuscitation & invasive procedures, Help with care -Give comfort measures: Pain management, Environment, Emotional support, Develop trusting relationship with client -History & Head to toe assessment: Assessment, History. Diagnostic peritoneal lavage (DPL) Inspect posterior surfaces: Assess back for ecchymosis, abrasions, puncture wounds, cuts, obvious deformities

Coronary Artery Bypass Graft Surgery (CABG)c

Revascularization of heart utilizing internal mammary artery (IMA) and/or saphenous vein for graft Goals: a) Increase blood flow to myocardium b) Relieve symptoms c) Prolong survival d) Improve quality of life Coronary artery bypass graft surgery. A, Saphenous vein is harvested from the leg using either a traditional long incision or less invasive videoscopic harvesting. B, The vein is then anastomosed to the coronary artery.

Most frequent location/site of MI?

Right coronary artery is the most common.

Complications of Aortic aneurysm

Rupture & Hemorrhage (massive): a) Due to rupture of untreated aneurysm b) Ruptures into thoracic or abdominal cavity untreated aneurysm that ruptures best chance for survival open on the OR table. c) Manifestations of hypovolemic or cardiogenic shock(hypotension, tachycardia, diaphoresis, nausea & vomiting, apprehension).

Myocardial Injury

ST elevation (due to decreased blood supply; ST returns to normal as injury heals)

Ventilation/Perfusion Mismatch

Shows the possibilities of dead space.

Clinical manifestations of Pulmonary hypertension

Similar to PE but now it is more widespread. 1. Dyspnea/Shortness of breath* most common as early manifestation and all related to that decrease oxygen transport thats occurring. 2. Fatigue* most common 3. Chest pain* generally is with exertion not generally at rest. most common 4. Pallor not perfusing the skin as well. 5. Syncope not perfusing the brain as well. 6. Right heart failure manifestations

SA node

Sinoatrial node Is where depolarization begins and there is atrial contraction or an atrial kick. 60 to 100 bpm dominant

Shock stages, collaborative care and diagnostics

Stages of shock: -Initial -Compensatory -Progressive -Irreversible Collaborative Care Goals: -Identify risk -Collect data -Control or eliminate cause -Protect organs -Supportive Care Diagnostic Studies: -ECG -Echocardiogram -Pulmonary pressures -Ultrasound -Laboratory values: WBC, Serum lactate, Blood cultures, ABGs -CT/MRI

Blunt Trauma

Such as in a car accident for example: -Deceleration thrown back happen on posterior wall, acceleration thrown forward happen on anterior wall, shearing and compression injuries -Can be life threatening

Care of Superficial and Minor Partial Thickness Burns

Superficial Burn: 1. Do not apply ice or submerge in ice water 2. May apply cold compress or run under cool water 3. A dressing not required - no open blisters 4. Lotion applied liberally 1-2 times a day 5. Ibuprofen, acetaminophen or aspirin for pain/discomfort 6. Drink plenty of fluids to re-hydrate 7. Rest Minor partial-thickness Burn: 1. If 1-3 quarter sized blisters, do not pop blisters 2. If blister broken, wash area with mild antiseptic soap and warm water 3. Apply thin layer of bacitracin ointment and cover with non- adherent dressing 4. Cleanse wound and change dressing at least once a day 5. May do ADL's but need to elevate affected extremity involved 6. Assess for symptoms of infection and report promptly if needed 7. Recommend see health care provider

Thoracotomy

Surgical procedure that involves opening the thoracic cavity.

Cranial Surgery

Surgical removal of a section of bone (bone flap) from the skull for the purpose of operating on the underlying tissues, usually the brain. Indications: -Brain abscess -Hydrocephalus -Brain tumors -Intracranial bleeding -Skull fractures -Arteriovenous (AV) malformation -Aneurysm repair Types: 1. Craniotomy -Frontal, parietal, occipital, temporal, suboccipital or combination -May have drain postop -Require ICU stay until stable 2. Stereotactic Radiosurgery -Linear accelerator, gamma knife or CyberKnife -Can obtain tissue samples -Uses precise focused radiation to destroy tumor cells 3. Craniectomy: Removal of portion of skull Complications: -Hematoma formation, bleeding -Cerebral edema -Vasospasm -Infection -DVT -Diabetes Insipidus -Syndrome of inappropriate ADH -Stress Ulcer (Curling's stress ulcer)

Myocardial Ischemia

T wave inversion, tall peaked T waves or ST depression (due to changes in tissue repolarization)

Team member roles

Team leader: -Usually first physician to arrive -The physician directs and coordinates the resuscitation efforts -A nurse who is trained in ACLS may direct the code until a physician arrives -Performs rapid assessment of patient and will ask for brief history of patient and events prior to code Intubator (Physician, Anesthesiologist, Respiratory Therapist, Nurse-anesthetist): -Equipment needed Compressor: -Nurse -Physician -Nurse Assistant/Attendants -Respiratory Therapist -Student Nurse -Change out should occur after two minutes/ 5 cycles -Check for perfusion and presence of pulse (can use Doppler) Ventilator: -Ambu with oxygen -Respiratory therapist Defibrillator Operator: -Physician or nurse trained in defibrillation delivers shock -Confirm everyone clear to prevent accidental shock Recorder: Documents on Resuscitation Record -Type and time of arrest -Respiratory management -Line placement and any other procedures or labs drawn -Medication administration times -I.V. fluids -Vital signs -Cardiac rhythms and Joules used to shock -Patient response to treatment -Patient outcome -Termination time of code -Attain signatures of primary team members -A CODE EVALUATION must be completed and sent to Risk Management Medication Nurse: -One nurse retrieves medications from cart (if pharmacist not available) -One nurse administers the medications -As the medication nurse, you MUST: a. Establish and maintain IV lines b. Calculate drug dosages c. Titrate drips d. Be familiar with compatibility and incompatibility of IV drugs e.Repeat the drug name and dosage ordered OUT LOUD as you draw up and administer medications Delegating/Additional Nurse: -Notifies the family and primary physician of resuscitation efforts -Contacts pastoral services if needed -May accompany the team leader to discuss what occurred with the family -Offer emotional support to family -Ensures continuation of care for all other patients on the floor

Electrical conduction system

The cells of the cardiac electrical conduction system that generate and conduct the action potential follow this pathway: 1. The impulse originates in the SA node. The SA node has an inherent rate of 60 to 100 bpm. 2. The impulse spreads through the atria through the internodal pathways to the... 3. Atrioventricular node, where the impulse is delayed to allow for atrial contraction and complete ventricular filling. 40 to 60 bpm. 4. It leaves the AV node through the bundle of His and branches off into the ... 20 to 40 bpm. 5. Right and left bundle branches, which travel down the interventricular septum to the end in the... 6. Purkinje fibers, which extend the impulse into the ventricular tissue, facilitating ventricular contraction.

Myocardial Infarction

The destruction of heart muscle from lack of oxygenated blood supply. -Contributing risk factors: modifiable and non modifiable -Can occur at any time of the day, but most dangerous time is early morning (6 am -12 noon). Causes: 1. Atherosclerosis 2. Coronary thrombosis and/or emboli 3. blunt trauma 4. Coronary artery spasm -ECG changes: 3 "I"s of an MI, NSTEMI< STEMI -Pathologic Q waves (due to scar tissue that cannot depolarize; will remain on 12 lead ECG -Depth of heart damage

Atrial Pacing

The electrode is placed in the atrium.

Contractility

The force of the mechanical contraction. Contractile force can be increased with sympathetic stimulation or calcium release. It can be decreased in the face of hypoxia or acidosis. - The squeezing of the heart.

Right Atrial Pressure (Central Venous Pressure)

The reading is displayed as a waveform on the monitor. The system consists of a transducer catheter attached to non compressible pressure tubing and a pressurized normal saline flush bag to prevent backup of blood. The bag is pressurized to 300 mmHg for the arterial catheter and 150 mmHg for the central venous and PA catheters. Evidence has demonstrated flush bags only need to pressurized, not heparinized; therefore, most institutions have changed their policies to reflect this standard. - is the blood pressure in the venae cavae, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood back into the arterial system.

Afterload

The resistance to flow the ventricle must overcome to open the semilunar valves and eject its contents. This is related to BP, vessel lumen diameter, and/or vessel compliance. The valves can meet resistance on both the right and left through the pulmonary artery or aorta. Hypertension on the right or left is implicated in the negative effects of increased afterload.

PR Segment

The time immediately following the P wave to the beginning of the QRS complex reflects the delay at the AV node.

Low Risk for Pulmonary Embolism

These are people that have no clear identified risk factors to begin with. But they might be at risk. -Normal BP, normal body weight. -No RV dysfunction -No increase in biomarkers

Electrodes

These are placed on specific positions of the body, bilateral upper and lower extremities and six positions around the left chest. There are different ways to use these 5 lead, 10 lead and 12 lead.

Partial Compensation

This example have metabolic acidosis with respiratory partial compensation. 1. Abnormal pH +2 abnormal values (pCO2 and HCO3). -pH: 7.31 -pCO2: 32 -HCO3: 18

Full Compensation

This example respiratory acidosis with compensation that has brought pH back within normal limits. 1. Normal pH +abnormal values (pCO2 and/or HCO3) -pH: 7.38 -pCO2: 49 -HCO3: 35

SVO2 monitoring

This reflects the amount of oxygenated blood returned to the right heart. Oxygen consumption is typically stable at the tissued level. Normal SVO2 values are between 60 and 75%. When the value falls below normal it means that tissues are extracting more oxygen than normal. That results from decreased DO2 (oxygen delivery) which may be a decrease in oxygen content, hemoglobin, or cardiac output.

Pneumonectomy

Thoracic Surgery. -Removal of entire lung tie off the bronchus on that one side and want the stump to scar up to be firm and when suctioning their trachea suction carefully to not cause any trauma to that area. -Lung cancer, malignancy, abscess

Decortication

Thoracic Surgery. -Surgical removal of pleural fibrous tissue and pus from pleural space.

Segmental Resection

Thoracic surgery. -Removal of bronchovascular segment

Wedge Resection

Thoracic surgery. -Removal of small wedge shaped section of lung tissue.

Lobectomy

Thoracic surgery. -Resection of one or more lobes of lung -Lung cancer, lung abscesses or cysts.

Surgical Management for chest trauma

Thoracotomy: exploratory surgery to help resolve whatever medical need there is.

Chest Tube Placement

To remove air, blood or fluid from pleural space (pleural tubes) and/or mediastinal space (mediastinal tubes).

Traditional CABG and risks associated with it

Traditional: 1) Wean from bypass & rewarm 2) Defibrillate as needed 3) Epicardial pacing wires (may be placed) 4) Mediastinal (used to prevent cardiac tamponade) and pleural chest tubes 5) Wire Sternum Risks associated with CABG 1) Left ventricular dysfunction 2) Emergency surgery 3)Age 4)Sex (female) 5)Number of diseased vessels 6)Decreased ejection fraction with heart failure

Tracheostomy

Types: -Cuffed versus cuff-less tracheostomy tube -Single versus double cannula -Fome cuff -Fenestrated tracheostomy tube -Speaking tracheostomy valves Indications: -Long-term mechanical ventilation -Frequent suctioning -Protecting the airway -Bypass an airway obstruction or trauma -Long-term mechanical ventilation -Frequent suctioning -Protecting the airway -Bypass an airway obstruction or trauma -Reduce work of breathing (WOB) Insertion: -Percutaneous insertion -Surgical placement -Check coagulation status Post insertion complications: -Accidental trach tube decannulation within first 72 hours (medical emergency) -Bleeding -Tube obstruction -Pneumothorax -Infection -Tracheal stenosis or tracheoesophageal fistula -Dislodgement with subcutaneous emphysema

Artificial airways

Types: -Laryngeal mask airway (LMA) -Endotracheal (ET) intubation -Tracheostomy Indications: 1) Upper airway obstruction (e.g., tumor, burns, bleeding) 2) Apnea 3) High risk of aspiration 4)Ineffective airway clearance 5)Respiratory distress 6)Administer general anesthesia

Acute Coronary Syndrome

Umbrella term used to describe the continuum of stable angina, unstable angina (UA),and MI. Stable angina and UA are episodes of intermittent chest pain present when the artery is narrowed 60% to 70 %.

Assist-Control Ventilation (A/C)

Used for patients who have weak respiratory muscles and may be unable to maintain adequate ventilation. 1. Volume assist-control (V A/C) -Delivers set rate and volume of breaths per minute and if client initiates spontaneous breath the same volume will be delivered for the breath -Pressure used to deliver volume will vary and will use whatever amount of pressure needed to deliver the preset volume -Set volume & pressure varies -Anticipated settings: Rate, Tidal Volume , PEEP, FiO2 2. Pressure assist-control (P A/C): -Deliver set rate and pressure limit for breaths per minute and if the client initiates spontaneous breath, the same pressure limit will be applied -Volume delivered per breath will vary. When pressure limit is met, ventilator stops delivering volume. 3. Disadvantages of A/C mode: -Risk of hyperventilation (due to pain, acid-base imbalance, anxiety) -Risk of respiratory alkalosis -Set pressure & volume varies -Anticipated settings: Rate, pressure limit, PEEP, FiO2

Mediastinal Tubes

Used to prevent cardiac tamponade.

Negative Pressure Ventilation

Utilizes chamber that encase chest or body and surround it with intermittent negative pressure (ex. Iron lung portable negative pressure ventilators). Rarely used.

Annuloplasty

Valve repair (mitral valve) repair the ring (annulus)

Resting State

When the heart is just sitting and waiting for the next impulse.

Indications for CABG

Why they might have bypass surgery. a)Failed medical management ACS b)Presence of left main coronary artery (widow makers) or 3 or more vessel disease c) Not a candidate for PCI (e.g., lesions long or difficult to access) d) Failed PCI with ongoing chest pain e) Diabetes mellitus with ongoing chest pain f) LVEF <35% g)Rescue procedure for coronary artery dissection

Ascending Aortic Aneurysm & Aortic Arch

a) Aortic regurgitation b) Heart failure symptoms c) Angina d) Hoarseness of voice e) If pressure on subclavian artery - neuro manifestations like transient ischemic attack (TIA) or stroke f) If pressure on superior vena cava - decreased venous return, distended neck veins, edema of face and arms

Complications of Stroke

a) Hemorrhage into area of infarction (hemorrhagic transformation): May be result of spasm of blood vessel b) Cytotoxic edema (cerebral edema) c) Chronic weakness or paralysis d) Contractures e) Unilateral neglect or inattention (agnosia) to one side of body: Not recognize or acknowledge one side f) Homonymous hemianopia (visual field deficit) g) Disorders of speech h) Apraxia (inability to carry out learned sequential movements on Command) i) Depression

Cuff Pressures

a. BP = SV x SVR b. MAP Systolic BP + 2(diastolic BP)/ 3 c. Average perfusion pressure. d. > 60 mmHg pressure needed to perfuse coronary arteries (70-90 mmHg ideal for cardiac patients). e. Accuracy of measurements g. Nursing implications: check equipment, use right size, check skin breakdown or sweat. h. Safety: size of the cuff matters. So that you are getting the most accurate blood pressure. Never turn off the alarms.

Spinal Cord Injury Classifications

a. Complete injury: Total loss of motor and sensory function below primary injury level

Pulse oximetry Hemodynamic monitoring

a. Continuous method of determining arterial oxygenation (SpO2) b. Normal 95-100% c. Accurate measurements may be difficult d. Used to evaluate effectiveness of O2 therapy. e. Trouble shooting: 1. assess waveform 2. assess pulse rate as compared to ECG heart rate 3. best location 4. Avoid cold extremity, restrained extremity or extremity used to measure BP.

Calculate heart rate

a. Count small squares (most accurate way to measure regular rhythm) between two R waves then divide that number into 1500. Count small squares between two P waves to get atrial rate b. Six-second ECG Strip - used for irregular rhythms. Count the number of R waves including extra beats and multiply by 10. For atrial rate, count the number of P waves and multiply by 10.

Hemodynamic monitoring system

a. Equipment: 1. catheter 2. Transducer with noncompressible pressure tubing, 3 way stopcock (reference stopcock) 3. Pressurized normal saline flush bag (300 mmHg pressure) 4. Monitor b. Accurate measurements

Transplant Complications

a. Graft rejection: -Hyperacute: -within minutes to hours after transplant -blood vessels rapidly destroyed -result of preformed antibodies against transplanted organ management: -No treatment -must remove organ -re-transplant if organ available -Acute: -most often occurs within first 6 months after transplant -mediated by recipient's lymphocytes or if recipient develops antibodies to transplanted organ Management: -usually reversible with additional immunosuppressants, corticosteroids, monoclonal or polyclonal antibodies Note: increased risk of infection 1st few months -Chronic: -occurs over months or years -irreversible -cause - unknown or due to repeated episodes of acute rejection -results in fibrosis & scarring -heart trans -accelerates CAD -lung trans - bronchiolitis obliterans -liver trans - loss of bile ducts -kidney trans - fibrosis & glomerulopathy Management:-No definitive therapy -provide supportive therapy b. Infection: Bacterial, fungal, viral (CMV - most common) c. Accelerated atherosclerotic heart disease d. Hypertension e. Cancer (malignancies) f. Recurrence of original disease g. Hyperglycemia (steroids)

CMs of spinal cord injuries

a. Levels of injury and degree of injury predict parts of body that may be affected b. Cervical injuries: -Above C4, inability to breathe -> require mechanical ventilation -Below C4, diaphragmatic breathing -> respiratory insufficiency -Numbness -Weakness or paralysis [quadriplegia (tetraplegia)] -Loss of bladder and bowel control -Pain -Spasticity c. Thoracic injuries: -Weakness, paralysis (Paraplegia) -Can include poor trunk control -Loss of normal bladder and bowel control -Numbness -Sensory changes -Spasticity -Pain d.Cervical and thoracic injuries: Paralysis of abdominal and intercostal muscles → ineffective cough → atelectasis or pneumonia e. Injury above level T6, decreased influence of sympathetic nervous system f. Other manifestations: Chronic pain, low blood pressure, inability to sweat below level of injury, decreased temperature control (Poikilothermism)

Major Coronary Artery that may be involved in an MI

a. Right coronary artery (RCA) b. Left coronary artery (LCA) (1) Left main (LM): (a) Widow maker (2) Left anterior descending (LAD) (3) Circumflex (CX) c. Locations (Surfaces of the heart (1) Anterior, Inferior, Posterior, Septal and Lateral surfaces

Pulse Oximetry

an oximeter that measures the proportion of oxygenated hemoglobin in the blood in pulsating vessels, especially the capillaries of the finger or ear.

Iatrogenic Pneumothorax

caused by medical procedures.

Pacemakers

devices that are used to deliver electrical current to cause depolarization when the normal conduction pathway is damaged or unable to generate an impulse. temporary or permanent pacing. Use a pacing circuit to do that.

Defibrillation

electrical shock that's going to be delivered to try and terminate pulseless rhythms such as ventricular fibrillation and to terminate pulseless v tach. not synchronized with any part of the electrical cycle it's just current that's delivered at the time you activate the device. This is the treatment of choice for ventricular fibrillation and pulseless V. Tach. a. background b. equipment c. procedure d. Nursing responsibilities

Hyperkalemia Management

evaluate how rapidly they need to reduce that K+ can they use a temporary measure depending on what the cause was or a more rapid reduction in their values. Really that's going to help determine if they need a temporary or permanent measure. (1) D50 W and IV Insulin - purpose to force K+ into cell (temporary measure) - for life-threatening levels. Used when need something quickly. But not necessarily permanently. (2) Calcium Chloride (temporary measure) - increases threshold potential. Less risk for developing these arrhythmias because of the accelerated repolarization. (3) Cation exchange resin products into GI tract such as Kayexalate (permanent measure) given through the GI tract PO, PEG tube, enema, NG tube, this would then be exchanging then with the K+ and causing it to be excreted from the body and is considered permanent. (4)Hemodialysis or peritoneal dialysis - removed directly (permanent measure) Hemodialysis Done fairly quickly if pt. is stable enough to get rid of the excess K+. Peritoneal dialysis if not stable enough do it more slowly.

Chest Trauma and types

in general about 16,000 deaths annually and about 25% of those are going to be related to thoracic trauma and most often those are going to be related to car accidents. Types: -Blunt -Penetrating

Cardioplegia

is intentional and temporary cessation of cardiac activity, primarily for cardiac surgery

I:E Ratio

measurement of client/ventilator produced data. -Inspiration: Expiration ratio - Normally 1:2 -Longer (1:4) in people with COPD to prevent breath stacking.

Antiplatelet Therapy for Stemi

o Action: Alter platelet aggregation; some agents prevent fibrinogen from binding on receptors on platelets. o Aspirin - 162 - 325 mg chewed immediately if no contraindication o Thienopyridines ♣ Clopidogrel, Prasugel, ticagrelor and ticlopidine ♣ All STEMIs unless surgery is needed, discontinue 5-7 days before CABG ♣ PCI with stent, preferred to continue for 12 months if possible o Glycoprotein IIb/IIIa inhibitors ♣ Action: Inhibit platelet function by blocking binding of fibrinogen to activated glycoprotein IIb/IIIa receptor complex ♣ Eptifibatide, abciximab, and tirofiban ♣ IV drip

Thrombolytics for STEMI

o Action: breaks up blood clots and increases blood flow o Streptokinase, alteplase

Anti-dysrhythmics for STEMI

o Action: controls rhythm disturbances o Amiodarone

ACE inhibitors/ Angiotensin receptor blockers for STEMI

o Action: decreases blood pressure and decreases remodeling of ventricular wall o ACEI or ARB given to all STEMI patients upon hospital discharge o ARB used when ACEI associated with cough or other side effects o Benazepril, captopril - ACEI o Losartan - ARB

Calcium channel Blockers for STEMI

o Action: decreases blood pressure, decreases oxygen demand, also may relieve coronary artery vasospasm o Diltiazem and verapamil used when contraindication to bets-blockers

Beta Blocker for STEMI

o Action: decreases heart rate, decreases blood pressure, decreases afterload and myocardial O2 consumption o Metoprolol - Antidysrhythmics and antihypertensive o Early intravenous administration when no contraindication exists and there is angina, hypertension or tachycardia o Oral beta-blocker therapy if do not need intravenous. o Not given in presence of signs of cardiogenic shock

HMG-CoA reductase inhibitors for STEMI

o Action: lowers lipid levels o Every STEMI should receive statin therapy o Atorvastatin

Anti-thrombin Agents for Stemi

o Action: prevents clots from becoming larger or other clots from forming o Unfractionated heparin, low molecular weight heparin (enoxaparin of fondaparinux) or bivalirudin

Morphine for STEMI

o Action: relieves anginal chest pain and sensation of dyspnea when pulmonary edema present

Intensive glucose therapy for STEMI

o Action: to maintain blood sugar 70-110 mg/dL o Insulin drip

Respiratory Acidosis

pH<7.35 PaCO2>45 Causes: -Hypoventilation (associated with respiratory failure from ARDS, severe asthma, pneumonia, COPD, sleep apnea) -Pulmonary embolism -Pulmonary edema -pneumothorax -respiratory center depression (Morphine, alcohol, barbiturates, sedatives, drug overdose) -neuromuscular disease with normal lungs -inadequate mechanical ventilation -sleep apnea Clinical Manifestations: -drowsiness, confusion, disorientation, dizziness -headache -hypotension -dysrhythmias (ventricular fibrillation) -warm flushed skin -seizures -decreased respiratory rate and depth of breathing -hypoxia Collaborative Management: -treat underlying cause -monitor for respiratory distress, electrolyte values esp. K+ -improve ventilation and lung expansion (cough & deep breath, incentive spirometry, ambulation, BiPAP or CPAP -encourage fluids, chest PT, postural drainage, suctioning -supplemental O2 for severe hypoxemia -monitor K+ level (will go up as pH goes down) -bronchodilators -avoid narcotics, sedation

Metabolic Alkalosis

pH>7.45 HCO3 > 26 Causes: -loss of body acids (NGT suction of HCL, vomiting, excessive diuretic therapy, steroids, hypokalemia) -ingestion of exogenous bicarbonate or citrate substances (excessive ingestion of antacids, MOM or soda) Clinical Manifestations: -drowsiness, dizziness, nervousness, confusion -tachycardia, dysrhythmias related to hypokalemia anorexia, nausea, vomiting -tremors -hypertonic muscles, muscle cramps -Tetany -tingling of extremities -seizures -hypoventilation Collaborative Management: -treat underlying cause -monitor for signs of respiratory distress, CNS depression, monitor I&O and electrolyte esp. K+ -decrease or stop acid loss (anti- emetics) -replace electrolytes including K+

Sepsis

the presence in tissues of harmful bacteria and their toxins, typically through infection of a wound. Sequential [Sepsis-Related] Organ Failure Score (SOFA): -qSOFA (Quick SOFA) Criteria: Respiratory rate > 22/min, Altered mentation, Systolic BP < 100 mmHg -SOFA: altered LOC, SBP <100, RR >22

Fourth Link Advanced Life support

• When a patient is in cardio or cardio-pulmonary arrest in the hospital setting, it is announced overhead Adult: -Code Blue -Dr. Emory House -Harvey Team Child: -Dr. Stork • Crash Cart

Medical Management for increased ICP

a) Treatment goal to decrease volume of brain water, blood or CSF b) Emergency management increased ICP: -Airway management because respiratory rate may change -Decrease intracranial contents: Osmotic diuretics, Hyperventilation?? -Monitor neurologic status - LOC c) Diagnosis: -CT or MRI of brain -EEG: evaluate the impact of brain tumors etc. -Cerebral angiography any abnormalities within the circulation not done too often invasive. -Cerebral blood flow studies with Doppler -NO LUMBAR PUNCTURES if you pull off cerebral spinal fluid could lead to alteration in intracranial pressure and cause more problems. -Laboratory testing: Serum osmolality, Arterial blood gases particularly the CO2 and metabolic component, Serum sodium, urine osmolality, CBC & coagulation studies any greater risk for bleeding. d) Medications: -Osmotic diuretic (Mannitol): Actions: osmotic effect, plasma expansion -Hypertonic saline IV: Actions: moves water out of cells and into blood, increases serum osmolality levels, main thing have to watch for is their sodium level. -Corticosteroids: Use: Vasogenic cerebral edema (primarily for brain tumors) -IV fluids to replace volume (compensate for systemic dehydration and hypovolemia) -Sedatives (may be used but avoid carefully to avoid masking subtle changes related to increased ICP): *must use appropriate choices of agents to avoid masking true neurologic changes. Avoid benzodiazepines due to hypotensive effect. -Antipyretics: Normalize temperature to decrease metabolic demand -Anticonvulsants: Prevent seizures to prevent increased metabolic demand -Neuromuscular blockers: Continue assess pupils [pupils not affected by neuromuscular blockers] -Barbiturates:Barbiturate coma therapy - used to control intracranial hypertension not responding to other therapies, Maintained on ventilator -GI prophylaxis: worry about still even though not neuro related. e) Physical interventions -Raise head of bed > 30 degrees -Position the patient with neck in neutral position and minimize hip flexion -Hyperventilation?? (risk global cerebral vasoconstriction and ischemia):Keep PaCO2 30-35 mmHg with hyperventilation -Minimize environmental stimuli: Keep calm & quiet, Control noise, temperature, noxious stimuli carefully, Avoid unnecessary conversations at bedside, Leave television off, Allow family to visit, but have them speak quietly. Monitor patient response to family, Space out activities of care -External drainage of CSF: (a) Continuous drainage (open): When pressure in brain exceeds level of drip chamber, CSF will drain out (b) Intermittent drainage (closed and intermittently opened to drain) openness means: intermittent means

Nursing actions for airways

a)Maintain proper cuff inflation (cuff pressure 20-25 cm pressure): 1) Minimal occluding volume (MOV) 2)Minimal leak technique (MLT) b) Provide oral care, monitor for skin breakdown (ETT - corners of mouth, mucous membranes, tongue; Trach - stoma and under flanges) c) Secure tube (tape, ties, tube tamer) [bite block avoided] d) Assess need for suctioning q1-2 hours and suction only as needed: 1) Indications for suctioning 2) Visible secretions in ET tube 3) Sudden onset of respiratory distress 4) Suspected aspiration of secretions 5) ↑ Peak airway pressures 6) Adventitious breath sounds 7)Respiratory rate and/or coughing 8) ↓ in PaO2 and/or SpO2 9) Procedure: a)Open versus closed versus closed: -Hyperoxgenate -Limit suctioning to <10 seconds -Monitor ECG for dysrhythmias, SpO2 -Limit suction pressure to <120 mmHg -Insert until client coughs or meet resistance whichever comes first 10) Complications of suctioning: - Hypoxemia, bronchospasm -Increased intracranial pressure -Dysrhythmias - ↑ or ↓ BP - Mucosal damage -Bleeding, pain, infection e) Provide for communication method appropriate to client f)Provide oral care per hospital protocol: 1) Brush teeth BID 2)Oral swabs with 1.5% hydrogen peroxide and/or mouthwash 3) Chlorhexidine oral rinse 4) Moisturizer 5) Oropharyngeal suctioning 6) Reposition and retape ET tube every 24 hours g) Perform trach care q shift & prn (change inner cannula q8h & prn) h) Manage thick secretions: 1) Adequate hydration 2) Supplemental humidification 3) No saline instillation 4) Antibiotics PRN 5) Mobilization, etc. i) Keep trach obturator and spare trach at bedside j) Monitor oxygen source (via mechanical ventilation, T-piece (provides high humidity and desired O2 concentration), tracheostomy collar (deliver humidified O2 in concentration prescribed) k) Monitor for complications: 1) Prevent aspiration: -Cuff inflation -Epiglottic suction -Increased salivation (need oral suctioning) -Prevent vomiting (orogastric, nasogastric tube LIS) -Increase HOB to 30-45 degrees 2)Prevent unplanned extubation: -Ensure adequate securement of ET tube -Support ET tube during repositioning and procedures -Provide sedation and analgesia as ordered -Use standardized weaning protocols -Use soft wrist restraints (requires HCP order) l) Troubleshooting: 1) Unplanned extubation a) Assess for: Patient vocalization, Activation of low-pressure alarm, Diminished or absent breath sounds, Respiratory distress, Gastric distention 2) Incorrect tube placement/Unplanned extubation - emergency: Stay with patient and maintain airway, Support ventilation , Call for help immediately, If necessary, manually ventilate with ambu bag & 100% O2. Teaching: -Explain procedures

Hypomagnesemia ECG Changes

(1) Like hypokalemia (2) Prolonged PR & QT intervals (3) Presence of U waves (4) T-wave flattening (5) Widened QRS complex (6) SVT, VT, Torsades de pointes related to prolonged U T interval , sudden cardiac death

Hypercalcemia Management

(1) Loop diuretics (acute management): Furosemide 1mg/kg along with NS to maintain stable body water, along with a K+ replacement (2) Calcitonin (slower to work) SQ or IM (3) Bisphosphonates slower to work (4) Hemodialysis more acutely

Hypomagnesemia Management

(1) Magnesium IV replacement: (a)No Pulse: 1-2 g in 10 ml D5W over 5-20 minutes as piggyback. (b) With a pulse: 1-2 g over 5 to 60 minutes diluted in D5W as well. (2) Evaluate renal function when administer Mg++ just to make sure they are at optimal function.

Hyercalcemia ECG Changes

(1) Shortened QT interval that's related to the shortening of the ventricular repolarization so the recovery time is quicker so that leads to a shortened QT interval. (2) Bradycardia (3) Heart block (1º, 2º, and 3º) & BBB bundle branch block means that there is a possibility of blocking within one of the bundle branches

Hypercalcemia Mechanisms

(1) Strengthens contractility (2) Shortens ventricular repolarization

Pulmonary Artery Catheter Insertions

(1) Follow guidelines for inserting CVAD (2) Sheath placement (3) During insertion, monitor waveforms (4) Check for proper wedging PWP (5) Verify placement and check for complications if balloon is checked too often it can loosen and loose pressure and could lead to a pulmonary infarction due to the looseness of the balloon from continuous checks to verify placement.

Complications from MI

(1) Heart failure (2) Pulmonary edema -types - cardiogenic, non-cardiogenic, neurogenic -manifestations -Management - suction as needed, maintain airway, elevate head of bed, high flow oxygen, emotional support -Medications - diuretics, morphine, vasodilators, inotropic agents, antihypertensives (3) Dysrhythmias -Sinus bradycardia, sinus tachycardia, atrial - PAC's, atrial fibrillation), AV heart blocks (most occur with inferior MI), bundle branch block (BBB), PVC's, Sudden cardiac death (ventricular tachycardia, ventricular fibrillation) (4) Cardiogenic shock (5) Ventricular septal defect (VSD) [holosystolic murmur] (6) Papillary muscle dysfunction (7) Ventricular aneurysm -Noncontractile, thinned left ventricular wall -Risk for clots and embolism (8) Dressler syndrome -Pericarditis with effusion and fever that develops 4-6 weeks after MI -Manifestations: pericardial (chest pain), pericardial friction rub, pericardial effusion, arthralgia -Treated with short-term corticosteroids

Medications for Hypertensive Crisis

(1) IV drug therapy titrated to MAP (a) Titrate IV meds to lower pressure cautiously (i) Initial goal: reduce by no more than 25% in first 2-6 hours. Monitor their BP every 15 min. during this time. Some exceptions (ii) Ischemic stroke: lower BP slowly by 15-20% going to be a little less aggressive in lowering pressure because we need to maintain their cerebral perfusion pressure so that we don't end up creating further problems with the stroke. (iii) Aortic dissection: keep SBP < 100 mmHg area of weakness in the wall. Rapidly reduce their pressure so that we don't increase the amount of dissection due to the high pressure on the area of weakness in the wall of where it is dissecting. (iv) Return to optimal pressure within 24 hours want to avoid lowering the BP too quickly or too much because of cerebral perfusion, coronary perfusion, and renal perfusion that we don't precipitate a stroke, MI or acute kidney injury. (b) Nitroprusside vasodialator: Ni-Prid (i) "Gold standard" usually use first (ii) Continuous infusion (iii) Risk of high dose nitroprusside: cyanide toxicity, monitor thyocyanide levels and they are light sensitive might see it in a foil bag, signs of toxicity might include weakness, Tinnitus ringing in the ears, confusion, seizures, and coma. Rarely get into the high ranges for seizures and comas monitor and know what safe range is. Requiring higher doses we want to be sure that they don't get too much fluid so they may concentrate that into a smaller amount of volume and we would double strength it where they put twice as much drug in the usual volume of fluid or they might use the same amount of drug and half the volume of fluid to try and get it more concentrated so you are giving less fluid. (c) Labetalol might supplement with this (i) Intermittent IV doses (d) Other drug therapy: (i) Fenoldopam (dopamine receptor antagonist) used more for renal patients to improve blood flow to kidneys (ii) Nitroglycerin given to improve angina and dilate the coronary arteries. (iii) Ace Inhibitors - enalapril, lisinopril, captopril) (iv) Calcium channel blocker - nicardipine, cardizem, verapamil (v) Alpha blocker - phentolamine (vi) Hydralazine (vii) Diuretics - furosemide if it is any way related to fluid.

Systemic Effects of major burns

(>20% of TBSA) 1. Respiratory: -Inhalation injuries -Respiratory distress -Endotracheal intubation 2. Cardiovascular -Burn shock: Distributive and hypovolemic shock combined, Fluid shift (fluid leak 8 - 36 hours) Decreased cardiac output, increased Hct, Fluid resuscitation (24-48 hours) 3. Fluid and electrolytes -Potassium: Hyperkalemia initially, Later hypokalemia -Sodium: Hyponatremia -Fluid loss (evaporation) -Facial edema before & after fluid resuscitation 4. Renal: -Decreased renal perfusion -Myoglobin and hemoglobin occlusion of renal tubules may occur -Risk for ATN 5. Gastrointestinal: Decreased absorption and GI motility 6. Metabolic -Hypermetabolic -Impaired thermoregulation 7. Immunological: Risk for infection and sepsis

Bone Marrow Transplant and peripheral blood stem cell transplant

(BMT) and (PBSCT) -Replace defective marrow/stem cells that have been destroyed by high doses of chemotherapy or radiation therapy and other cancers • Indications: leukemia, multiple myeloma, lymphoma • Types of Donor Stem Cells: -Allogeneic - usually donor sibling, parent, or unrelated donor -Syngeneic - donor identical twin -Autologous - self-donor (burns such as skin grafts)

Chronic Liver Failure

(Cirrhosis) -Chronic progressive, irreversible, inflammatory disease of the liver -Slow deterioration evolving over years -Cell destruction and fibrosis or scarring of hepatic tissues -Cells die, regenerate into nodules and surrounded by fibrous tissue -Altered blood and lymph flow Hepatic insufficiency, portal hypertension -can lead to > varices which can then lead to bleeding Types (based on cause): -Chronic infection with Hepatitis B and C viruses -Alcoholic (Laënnec's) - Cl manifestations -vascular or arterial spider angiomas on abdomen, reddened palms (palmar erythema) -Post necrotic - bands of scar tissue in liver due to previous acute viral hepatitis or exposure to hepatotoxins -Biliary - scarring around bile ducts and lobes of liver; develop severe pruritus due to retention of bile salts -Non-alcoholic fatty liver* (also known and nonalcoholic steatohepatitis [NASH]) - accumulation of fat in liver cells, inflammation -Genetic -Autoimmune -Exposure to hepatotoxins, medications, parasites, cardiac dysfunction (Right heart failure)

Diabetes Insipidus

(DI) Anterior Pituitary Disorder "not washing sodium away" "washing machine" hypernatremia A. Hyposecretion of Antidiuretic hormone (ADH) - Description -Pituitary gland disorder - disorder -Hyposecretion (synthesis or release) of ADH (deficiency) or decreased kidney responsiveness to ADH -Kidneys fail to reabsorb water B. Classifications -Neurogenic (central): decreased secretion ADH: Causes - genetically predisposed, head trauma, increased ICP, neurosurgery, tumors, infection, pituitary surgery -Nephrogenic: kidneys resistant to ADH and kidneys unable to concentrate urine: Causes - genetically predisposed, chronic renal disease, polycystic disease, pyelonephritis, medications (ethanol, phenytoin, lithium carbonate, demeclocycline, amphotericin, multiple myeloma, sickle cell disease, cystic fibrosis -Idiopathic: Secondary to destruction of cell of the hypothalamus that produce ADH, May be autoimmune process -Psychogenic: Turns off the ADH production, Results from intake of large amounts of water (5 liters a day)

Neurogenic Shock

(Form of distributive shock) Loss of sympathetic nervous system influence leading to massive peripheral vasodilation causing venous pooling and decreased cardiac output. (vessels cannot vasoconstrict) -Causes: SCI: cervical or high thoracic injury (T6 or higher), regional spinal anesthesia. -Hemodynamics & CMs: Hypotension Bradycardia -profound Decreased CO Decreased RAP Decreased SVR Decreased SVO2 Warm, dry skin Flushed Bowel/Bladder dysfunction -Management/treatment: Focus on cardiovascular support while find the cause of shock Atropine to increase HR, pacemaker if not responsive to Atropine Vasopressors to increase BP Cautious fluid resuscitation

Guillain Barre Syndrome

(GBS) -Acute infectious neuronitis of cranial and peripheral nerves -Immune system overacts to infection and destroys myelin sheath -Recovery can slow and take years Causes: -Usually preceded by mild upper respiratory infection or gastroenteritis Cms: 1. Symmetrical ascending motor weakness and paralysis (usually starts in feet and extends to trunk and arms 2. Parasthesias 3. Pain and/or hypersensitivity (sheets touching the body, etc) 4. Diminished or absent deep tendon reflexes 5. Possible progression to respiratory failure (weakness of diaphragm and intercostal muscles) 6. Cranial nerve involvement: a. VII - facial - difficulty smiling or frowning b. IX to XII may be involved - dysphagia c. X - leads to autonomic dysfunction (dysrhythmias, orthostatic hypotension, paralytic ileus, urine retention, SIADH)

Glasgow Coma Scale

(GCS) Start testing content for the test have to have a description of somebody based on eye opening, motor response, and speech. the higher the score the better. -Utilized to assess level of consciousness. -Scores eye opening, best motor response and verbal response -Best possible score: 15.

CMs of Multiple Sclerosis

(Intermittent or mimic other diseases) -Numbness or weakness in one or more limbs -Partial or complete vision loss, often with pain during eye movement -Double or blurred vision -Tingling or pain -Electric shock sensation that occur with head movements -Tremor, lack of coordination, or unsteady gait -Fatigue -dizziness

Myasthenia Gravis

(MG) -Acquired autoimmune neuromuscular junction disorder -Characterized by considerable weakness and abdominal fatigue of the voluntary muscles Causes: -Insufficient secretion of acetylcholine -Excessive secretion of cholinesterase -Unresponsiveness of muscle fibers to acetylcholine

Multiple Sclerosis

(MS) -Chronic neurological disorder -Inflammation destroys the myelin -Nerves of CNS degenerate and build up scar tissue (sclerosis) or plaques during demyelination of the sheath -Risk factors: positive family history, immunological factors, viral infections. Types: a. Relapsing-remitting: -Most common -Lasts days to months b. Secondary progressive -Progression of relapsing-remitting type with worsening of disease -No recovery occurs c. Progressive relapsing -Gradual worsening of symptoms and relapses may or may not have recovery d. Primary progressive -Gradual progression with no remissions -May experience temporary plateaus

Pulmonary Hypertension

(PAH) pulmonary artery hypertension. -Constriction of pulmonary blood vessels -Progressive, chronic, incurable Characterized by: -Pulmonary artery systolic (PAS) pressure >30mmHg and/or high mean. -Pulmonary artery mean (PAM) pressures > 25 mmHg can have one or both of these present. -Persistent high pressures lead to right ventricular failure because it has to work harder due to the high pressure required to flow properly. -No cure

Asystole

-No cardiac output ECG Characteristics: -Ventricular/Atrial Regularity: None -Ventricular Rate: None -P waves: None or not conducting to ventricles -PR Interval: None -QRS Duration: None

Positive End-Expiratory Pressure

(PEEP): a) Positive pressure applies at end of expiration b) Keeps alveoli open and to facilitate oxygen transport c) Recruits collapsed alveoli d) Prevents alveolar collapse e) Can cause reduced cardiac output if high amount of PEEP and impede venous return and lead to hypotension f) Usual setting: 3-5 cm H2O; higher level may be needed with decreased lung compliance

Rapid Response Team

(RRT) or Medical Response Team (MRT) •Team members - Nurses (BLS & ACLS trained), Respiratory Therapist, Physician • Goals of RRT/MRT: -Identify clients at risk for Myocardial infarction -Early identification of clients deteriorating -Identify clients at risk for breathing problems -Decrease code rates -Decrease mortality rates Responsibilities include: -Responding to the call or page within minutes -Assessing the client -Reviewing the client's history, medications -Documenting on Rapid Response Record: Why called Patient condition upon arrival What interventions took place Patient response to interventions Disposition of patient: - remain on the floor -transferred to an intensive care setting What physician was notified

Spinal Cord Injury

(SCI) -Damage or trauma to spinal cord when bone, disc material or foreign body enters the spinal canal & disrupts spinal cord or it's blood supply -Functional loss of mobility and/or sensation -Average age now 41 at time of injury; 80% males(higher risk activities); 56% cervical injury -Causes: varying degrees of paralysis, loss of sensation below injury level -Impacts - physical, emotional and social function B. Injuries resulting in spinal cord injuries: -Concussion: temporary loss of function -Contusion: bruising apart of the spinal cord could be bleeding into it. -Compression: edema -Tearing: leads to some type of permanent injury in the spinal column -Laceration:partial impairment -Transection: complete severage of the spinal cord -Ischemia -Trauma from bone fractures -Trauma to blood vessels & bleeding C. Causes: -motor vehicle collisions most common cause -Falls -violence -sports injuries -other miscellaneous causes D. Injury: -Primary injury i. Initial mechanical disruption of axons because of stretch or laceration ii. By ≤24 hours, permanent damage may occur because of edema. -Secondary injury: i. Ongoing, progressive damage that occurs after initial injury -Extent of damage determined by both primary injury and secondary injury -Prognosis cannot be determined for at least 72 hours.

Syndrome of inappropriate ADH

(SIADH) Anterior Pituitary Disorders "too much water not enough sodium" Increase amount of ADH. Characterized by water overload and resultant hyponatremia due to hemodilution Causes: -CNS disorders (tumors in brain and neck), side effects of medications (NSAIDS, psychotropics), bronchogenic cancer CMs: -Decreased urine output -Result from hyponatremia a. Early - anorexia, nausea, malaise b. Headache, irritability, confusion, weakness c.Seizures or coma (sodium <115)

Supraventricular Tachycardia

(SVT) Tachycardia that originates from above ventricle. -Abrupt onset and termination ECG Characteristics: -Ventricular/atrial Regularity: Regular -Rate: 150-250 beats per minute -P waves: Frequently buried in preceding T waves and difficult to see -PR Interval: Usually not possible to measure -QRS Duration: Usually 0.04 to 0.10 sec by may be wide if abnormally conducted through ventricles

Transient Ischemic Attack

(TIA) mini strokes a warning sign that they have a problem. -Ischemic warning attack -Associated for increased risk of stroke -Transient neurologic dysfunction due to ischemia -Symptoms typically last <1 hour and do not result in tissue infarction. Surgical therapy for TIA/Stroke preventions: -Carotid endarterectomy -Stenting -Transluminal angioplasty always a procedure with a balloon -Extracranial intracranial bybass. Postoperative Care: -Neurovascular assessment -BP management -Assessment of stent occlusion or retroperitoneal hemorrhage as complications -Minimize complications at insertion site.

Transvenous pacing

(TVP) Endocardial: transvenous pacing lead and external pacemaker.

Tidal Volume

(VT): a) Volume of preset oxygen delivered with each breath b) Usual setting: 8-10 mL/kg (based on client's ideal weight) c) High volume setting places client at risk for barotrauma or lung injury d) Low volume setting may be used clients with ARDS

Clinical Manifestations of MI

(a) Chest pain - shoulder, arm pain, jaw, tooth pain, shoulder blade pain, upper back pain (b) Shortness of breath (c) Nausea and vomiting (d) Sweating (diaphoretic), cool & clammy, pale (e) Generalized fatigue (f)Dysrhythmias (g) Temperature elevation (up to 100.4 F) in first 24 hours (h) RV infarction: jugular vein distention, hypotension, bradycardia (i) LV infarction: (worse prognosis), high risk sudden cardiac death, heart failure, (dyspnea, crackles, tachycardia, hypertension) (j) Women may have atypical presentation - neck, shoulder blade, and jaw pain and abdominal pain; may have no pain, just extreme fatigue, weakness, shortness of breath, may have sleep disturbances, light-headiness

MI Management

(a) Laboratory testing: (1) Biomarkers -Troponin, CK-MB, Myoglobin (See Attachment A) (2) CMP (Blood glucose) (3) CBC (WBC) but not significant enough to indicate infection. (4) Coagulation studies (b) Diagnostic testing: (1) 12 lead ECG (2) Echocardiogram (3) Stress Testing (4) Coronary angiography (c) Treatment: (1) Pre-hospital actions -Onset of symptoms -Immediately call 911 -Chew up one aspirin (325 mg) Emergency Medical Services -Assess client, attach to monitor & pulse oximetry, determine need for oxygen, administer nitrates -transport to closest hospital Emergency Department Care/Priorities -Assess vital signs, chest pain, level of consciousness -Assess ABC's first, airway, breathing, circulation - Administer oxygen to keep SaO2 > 90% - Begin cardiac monitoring and obtain 12 lead ECG (within 10 minutes of arrival) -Administer medications -nitroglycerin SL (hold if BP<90), aspirin if has not taken already -Insert IV access if not already initiated. -Elevate the head of bed -Check lab and biomarkers -Administer other medications - Morphine for pain, Vasoactive agents to support BP as needed -Prepare for reperfusion therapy (See below) (2) Diagnosis of MI - presence of biomarkers, symptoms of ischemia, ECG changes indicative of new ischemia, or development of Q waves (3) Provide oxygenation (4) Control pain, dilate coronary arteries, prevent clots, decrease myocardial workload (demand) Morphine Oxygen Nitroglycerin Aspirin (5) Next care directed at increasing blood flow to the cardiac tissue (reperfusion therapy) (d) Medications (See HANDOUT Medications ACS for STEMI (e) Reperfusion therapy-STEMI or NSTEMI with positive cardiac markers f) Cardiac rehabilitation (g) Surgical management (1) Coronary artery bypass grafting

Diet medications, surgical management, complications for chronic liver failure

(for clients without complications) -High in calories (3000 calories/day) [frequent, small feedings] -↑ Carbohydrate -Moderate to low fat -Protein restriction rarely justified-Protein supplements for protein-calorie malnutrition -Low-sodium diet for patient with ascites and edema -Vitamin A, B complex, C, K, folic acid to correct abnormalities Enteral or parenteral nutrition Medications: -Diuretics -Electrolyte replacements -Ammonia reducing medications Surgical: -liver transplant Complications: -Ascites -Portal hypertension with bleeding varices -Hepatic encephalopathy -Renal impairment

Septic Shock

(form of distributive shock). Sepsis is a systemic inflammatory response to a documented or suspected infection. Septic shock is the presence of sepsis with hypotension despite adequate fluid resuscitation, along with inadequate tissue perfusion resulting in hypoxia. -Causes: Any type of infection (UTIs, pressure ulcers, VAP, bug/animal bites, etc. ) -Hemodynamics & CMs: Quick SOFA Criteria: -Altered mental status -SBP ≤100 mmHg -RR ≥ 22 SEPSIS (Mnemonic) -Shivering, fever, very cold, -Extreme pain or general discomfort -Pale or discolored skin -Sleepy, difficult to rouse, confused -I feel like I might die -Short of Breath Hemodynamics Early (hyperdynamic): -Increased CO -Decreased RAP -Decreased SVR -Increased SVO2 -Nml/decreased BP -Tachycardia -Hyperthermia Late (hypodynamic): -Decreased CO -Variable RAP -Variable SVR -Decreased SVO2 -Hypotension -Tachycardia -Hypothermia -Diagnostic Procedures: WBC increased or decreased Decreased Platelets Increased Lactate Increased Blood Glucose Positive blood cultures -Management/treatment: 3-hour bundle: Measure a lactate level Obtain blood cultures prior to administration of antibiotics Administer broad-spectrum antibiotics Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L 6-hour bundle: Apply vasopressors to maintain a MAP ≥65 mmHg In the event of persistent hypotension after initial fluid administration (MAP < 65 mmHg) or if initial lactate was ≥4 reassess volume status and tissue perfusion. Re-measure lactate if ≥4

Cardiogenic Shock with shock outline

(pump problem) Severe impairment of ventricular contraction with adequate vascular volume that leads to tissue hypoperfusion. -Causes: AMI, Cardiac arrest, severe heart failure, cardiomyopathy, blunt cardiac trauma, cardiac tamponade, ventricular hypertrophy, valvular stenosis or insufficient, dysrhythmias -Hemodynamics& CMs: SBP <90 mmHG, HR > 100 bpm, Decreased CO, Increased RAP, Increased SVR, Decreased SvO2, Decreased LOC, Cool, pale, moist (clammy) skin, UOP < 30 cc/hr, Tachypnea with crackles, JVD, Weak, thready pulse. -Diagnostic Procedures:12 Lead ECG, Cardiac Enzymes , Chest x-ray -Management/Treatment: Stabilize oxygenation airway & increase BP Medications: Vasopressors (norepinephrine, Dopamine) Dobutamine Vasodilators (nitroprusside, nitroglycerin) Diuretics (furosemide)? Morphine Surgical Revas as needed Mechanical Assistance: IABP VAD (Impella)

Biologic valve replacement

(tissue) should not hear anything abnormal. -Bovine (cow), porcine (pig), and human -Short term anticoagulation may be used -Less durable

Commissurotomy

(valvotomy) valve repair. Incise fused leaflets to widen opening.

Apnea

(ventilator does not detect spontaneous ventilation in preset time) Causes: a. over sedated b. neurologic or metabolic problem Troubleshooting/Interventions: a & b. Determine cause, ambu patient and notify RT to assist with ventilator management. Manage cause of apnea.

Submassive Pulmonary Embolism

-Normal BP -Likely to have some type of RV dysfunction (visible on echo) -Myocardial necrosis or with a mild to moderate dysfunction and may be showing strain of that ventricle).

Management of rib fractures

-NO strapping or binding chest -NSAIDs, opioids, nerve blocks -Severe chest wall instability may require operative stabilization -Patient education: Deep breathing and coughing, Incentive spirometry, use appropriate use of analgesics.

Medications and diet for acute Pancreatitis

-Analgesics: manage pain, scheduled doses or continuos infusion/epidural infusion, opioid narcotics (morphine) -Anticholinergic agents -Spasmolytics -H2 antagonists or proton pump inhibitor -Pancreatic enzymes -Octreotide -Antibiotics Diet: -Mild pancreatitis: oral intake in a few days of onset pain -Moderate to severe: enteral nutrition with jejunal feedings; progress to small, frequent feedings (high carbohydrate) and fat soluble vitamins, no alcohol.

Factors that influence cerebral blood flow and ICP

-Arterial pressure (hypertension or hypotension) -Venous pressure -Intra-abdominal and intra-thoracic pressure -Posture -CO2 levels -Acid-base imbalances -Metabolic rate

Emergency Management of chest trauma

-Assess airway, breathing, circulation - findings will guide management -Ensure patent airway. Assess for signs of respiratory distress (dyspnea, cyanosis, tracheal deviation, O2 sat). May require intubation with mechanical ventilation -Keep pulse oximetry >90% - administer oxygen as needed -Prepare for Chest tube insertion (pneumothorax, hemothorax) -Maintain hemodynamic stability along with vital signs -Establish IV access with two large bore catheters. emergency axes to give large amounts of fluid or blood. -Begin fluid resuscitation as appropriate -Manage pain Other interventions: -Remove clothing to assess injuries -Cover sucking chest would with nonporous dressing taped on three sides. -Stabilize impaled objects. until physician is there or when they are taken to surgery to remove it. -Assess for other significant injuries and treat appropriately. -Stabilize flail rib segment. use tape to splint the area -Place patient in a semi-Fowler's position or position of comfort. -Prophylactic antibiotics may be prescribed if high risk for infection NOTE: small pneumothorax may allow to resolve spontaneously if it is small enough.

Management of PVC

-Assess client's signs and symptoms -Assess for cause and treat cause: drug induced (caffeine, alcohol, cocaine sympathomimetic drugs), hypoxia, cardiac disease, ACS, cardiomyopathey, vent aneurysm, metabolic imbalance, acidosis, hypokalemia, irritation of ventricle -Antidysrhythmic medication

Third Degree AV Block

-Atria and ventricles beat independently of each other and rates different -P's not related to QRSs -P waves not associated with QRS complex: PP intervals regular, RR intervals regular -Complete heart block -Junctional or ventricular escape rhythm -Assess for cause and treat -May need pacemaker -Hemodynamic status based on ventricular rate (CHB) ECG Characteristics: -Ventricular/Atrial Regularity: Usually regular, but atria and ventricles act independently -Rate: Atrial rate: 60-100; Ventricular 40-60 beats /min if originates from junction, or <40 if originates from ventricles -P waves: Normal (upright and uniform), may be superimposed on QRS complexes or T waves -PR Interval: Varies greatly -QRS Duration: May be normal (O.04-0.10 sec), or wide (>0.10 sec)

Surgical Management of Pulmonary Hypertension

-Atrial septostomy :creating a right to left shunt to help decompress the failing right ventricle if they are not responding to therapy. When this happens increase the amount of blood returning to the left side of the heart that's not oxygenated and may cause an increase in hypoxemia. -Pulmonary thromboendarterectomy: chronic thromboembolic pulmonary hypertension to try and improve their hemodynamics and functional status. -Lung transplantation (whole lung transplant) or heart/lung transplant would be indicated when the pulmonary hypertension has progressed despite all of the optimal medical therapy and surgeries measures often will go ahead and do heart transplant as well because of all of the changes.

Causative organisms for Endocarditis

-Bacterial most common is streptococcus viridans or Staphylococcus aureus. -Viruses -Fungi

Pulmonary Embolism

-Blockage of 1 or more branches of pulmonary artery. -Causes impaired ventilation perfusion ratio (ventilation-perfusion mismatch) and its going to be dead space ventilation because your going to have an area of lung tissue alveoli that are not participating in the gas exchange because the blood flow is blocked to that area. -Leads to hypoxemia.

Diagnostic tests: Post transplant

-Blood tests -Ultrasound -X-rays -Biopsies -Allomap molecular expression testing (heart transplants) -ECG -Echocardiogram -Pulmonary function tests b. Client education - Post-transplant -Medications: *Immunosuppressants and other prescribed medications -Followup visits -Wellness appointments -Exercise -Lifestyle changes

Management of PEA

-CPR -Oxygen -Epinephrine -Treat underlying causes "H's" and "T's" H's: -Hypoxia -Hypovolemia -Hypothermia -H+ ions (acidosis) -Hypokalemia or hyperkalemia T's: -Tablets (overdose) -Tamponade (cardiac) -Tension pneumothorax -Thrombosis (coronary) -Thrombosis (pulmonary)

Pulseless Electrical Activity

-Can be in rhythm but no pulse (PEA) ECG Characteristics: -Ventricular/Atrial Regularity: Reflects underlying rhythm -Ventricular Rate: Reflects underlying rhythm -P waves: Reflect underlying rhythm -PR Interval: Reflects underlying rhythm -QRS Duration: Reflects underlying rhythm Organized electrical activity is observed on the cardiac monitor but the patient is unresponsive, is not breathing, and has no pulse.

Complications of Acute respiratory failure

-Cardiac Failure -Multi organ dysfunction -Death

Teaching for CV surgery

-Cardiac rehabilitation referral: have them begin to exercise after surgery. -Lifestyle modification: low sodium, low cholesterol, low fat diet; smoking cessation; exercise -Medications: ASA, beta blocker, ACEI (if LVEF <40%)

Electrical Burns

-Cause: Coagulation necrosis from intense heat generated by electrical current; high or low voltage. -May cause muscle spasms. -Severity injury depends on: amount of voltage, tissue resistance, current pathways, surface area, duration of flow. -Injuries: Damage to nerves and vessels; damage to major organs; tissue anoxia, death. -Risk for: fractures, dysrhythmias, severe metabolic acidosis, myoglobinuria, ATN.

Smoke and Inhalation Injuries

-Cause: Inhalation hot air or noxious chemicals includes metabolic asphyxiation (carbon monoxide) -Major predictor of mortality in burn patients. -Injuries: Redness, edema, metabolic asphyxiation, upper airway, lower airway. -Risk for: Carbon monoxide (CO) poisoning death; mechanical obstruction; pulmonary edema; ARDS 1. Manifestations: -Facial burns -Singed nasal and facial hairs -Carbon in sputum -Anxiety and agitation -Respiratory distress: Stridor, progressive hoarseness, rales, rhonchi, retractions 2. Upper airway injury: -Injury to mouth, oropharynx, and/or larynx -Swelling 3. Lower airway injury: -Injury to trachea, bronchioles, and alveoli -Injury is related to length of exposure to smoke or toxic fumes -Wheezing and tracheobronchitis -Pulmonary edema may not appear until 12 to 24 hours after -Manifestations of ARDS

Ventricular Fibrillation

-Chaotic pattern -No discernible P, Q, R, S, or T wave -Coarse versus fine -No cardiac output; life-threatening -Emergent defibrillation -ALWAYS assess pt. for pulse and consciousness. ECG Characteristics: NO HEART RATE -Ventricular/Atrial Regularity: Chaotic -Ventricular Rate: Indeterminate -P waves: None -PR Interval: None -QRS Duration: None

Management Ventricular Fibrillation

-Check for pulse -No pulse, then shock -Perform CPR until defibrillator available for 5 cycles (about 2 minutes) -Defibrillate as soon as defibrillator available -Check for pulse -Medications: epinephrine

Classifications of Endocarditis

-Classified as right or left heart endocarditis can have one or the other the left side is probably more common. -Acute or subacute

Management Asystole

-Confirm client unresponsive and has no pulse -Check second ECG lead to confirm not V fib -CPR -Establish vascular access -Administer epinephrine every 3-5 minutes

Surgical Management of traumatic brain injury

-Debride & clean wound -Removal of bone fragments -Craniotomy, burr holes - hemorrhagic injuries -Craniectomy if extreme swelling -Hematoma evacuation Complications: -Infection CNS (meningitis, encephalitis)

First Degree AV Block

-Delayed conduction from SA node to AV node. -Same PR interval for each beat -Must identify the underlying rhythm ECG Characteristics: -Ventricular/Atrial Regularity: Regular -Rate: Depends on underlying rhythm -P waves: Normal (upright and uniform) -PR Interval: Prolonged (greater than 0.20 sec) -QRS Duration: Normal (O.04-0.10 sec)

Cms of GI bleeding

-Depend on rate and amount of blood loss, patient's age, overall health status -Hematemesis -Melena or maroon colored stools -Hematochezia -Epigastric pain -Abdominal distention -Bowel sounds increased or decreased -If loss of >25% of blood volume, altered hemodynamic status.

Clinical Manifestations of Peptic Ulcers

-Depend on ulcer location and client age. -Older adults may have few or no manifestations. -Pain: tends to recur at intervals of weeks or months, during exacerbation, occurs daily for period of several weeks then remits until next recurrence, acute pain may indicate complication. -Nausea and vomiting (occasional). Complications: -Perforation: sudden, intense epigastric pain, rigid abdominal muscles

Surgical Treatment for chest trauma

-Dependent on severity -Stabilize flail chest

Hypertensive Emergency

-Develops over hours to days shorter period of time. -Severely elevated BP (often >220/140 mmHg) -Evidence of target organ (end-organ) damage (heart, brain, kidney, retina, peripheral vascular system-aorta) related to acute hypertension -Require critical care admission to manage elevation and return to optimal level and whatever target organ damage they have.

Donor Post Harvest care

-Direct pressure applied over site for 5-10 minutes or until bleeding stops: Continue to assess harvest site for bleeding -IV fluids - hydrate before and after procedure to try and replace the volume. -Analgesics for pain - mild analgesics (may experience pain at harvest site up to 7 days - donor will replenish bone marrow in a few weeks

Teaching for Pulmonary Embolism

-Disease process want to make them aware of how to change their lifestyle. -Risks of PE and avoidance of future occurrences is what we are striving for. -Medication teaching explaining any that they are going to be discharged on. -Bleeding precautions related to their anticoagulation that they will be sent home on. -Adequate hydration: without overhydrating we don't want them dehydrated we don't want the blood more viscous but we don't want them in fluid overload either. -Limit foods high in Vitamin K because they will likely go home on warfarin. -Exercise: will be encouraged aerobic exercise helps decrease blood stasis and help them reduce weight if they are overweight encourage them to be up and moving especially if they are on a flight need to get up and move about every hour. If they are not able to get up and walk around on a flight they could wear compression socks or do ankle pumps. -Smoking cessation: because smoking increases their changes of clotting. -Signs and symptoms DVT

Nursing Interventions Assessment for CV surgery

-Neurologic status -ECG rhythm -Lung sounds -Chest pain -Urine output -Laboratory tests (CMP, CBC, Troponin after surgery could be elevated but should start to drop gradually, CK-MB same as troponin, Renal and liver) function tests, BNP -Activity tolerance: early mobility faster recovery.

Atrial Flutter

-Ectopic foci in atria, heart disease -Classic "sawtooth" pattern in leads II, III, and aVF -Atrial rate fast and regular with AV block (typically 300). -Degree of conduction varies; may be 2:1, 3:1, 4:1 etc. ECG Characteristics: -Ventricular/atrial Regularity: Atrial rhythm: regular; Ventricular rhythm: variable -Ventricular/atrial Rate(s): Atrial rate: 250-350 beats/min; Ventricular rate variable -P waves: Flutter waves have saw-toothed appearance; some may not be visible, being buried in QRS -PR Interval: Not measurable -QRS Duration: Usually normal (0.04 to 0.10 sec), may appear widened if flutter waves are buried in QRS

Ventricular Assist Device (VAD)

-Electrical device used to support heart function, reduce workload and improve CO. Mechanical pumps used to assist ventricles and decrease ventricular workload. -Impella: directly unloads left ventricle -May be utilized with MI, cardiogenic shock, bridge to heart transplant. Key Points: -Requires anticoagulation -High risk infection -Nursing management - like care with IABP -Complications - bleeding, tamponade, heart failure, infection, dysrhythmias, renal failure, hemolysis, thromboembolism

Surgical Management of Pulmonary Embolism

-Embolectomy (massive PE - hypotension) if it is a massive PE and hemodynamically unstable and exhibiting hypotension then they may go in and o this. This is a highly invasive procedure have to have a cardiopulmonary bypass available for this surgery. Have to be extremely unstable to try this approach. 1) Thoracic surgery with cardiopulmonary bypass -Inferior vena cava filter (IVC) placed in the inferior vena cava. 1) prevent emboli from legs, pelvis and inferior vena cava, from traveling back to the lungs. So have three different examples of filters and some called umbrellas, so try to collect those emboli and have them stick to this network and then allow the body's normal fibrinolytic system to break them down. 2) Complications: filter migration, erosion of vena cava wall less often happens, obstruction of filter if they have lots of debris or clots many times these are only used temporarily.

Atrial Fibrillation

-Erratic impulse formation in atria -Aberrant (abnormal)ventricular conduction can occur -Causes: Heart disease, ischemia, mitral or tricuspid valve disease, CHF (overstretched chamber) ECG Characteristics: -Ventricular/atrial Regularity: Irregular always -Ventricular/atrial Rate(s): Atrial rate greater than 350 beats/min; Ventricular rate variable -P waves: No true P waves; chaotic atrial activity -PR Interval: None -QRS Duration: 0.04 to 0.10 sec

First Link - Recognition & Activation of Emergency Response System (EMS)

-Establish patient unresponsive and call for help and AED -Accessing 911 outside the hospital setting or calling for help in the hospital setting is vital to the patient's chance of survival -For every minute that passes the patients chance of survival decreases by 7-10% -Brain damage and permanent death can occur within 4-6 minutes and lead to permanent disabilities -After 10 minutes, attempts at resuscitation are often futile

Stable Angina

-Extertional angina with predictable pattern -Chest pain relieved by rest

Prevention for acute liver failure

-Following instructions on medications -Tell HCP about all medications including over-the-counter and herbal meds -Drink alcohol in moderation or not at all -Avoid risky behaviors (illicit IV drugs, not share needles, use condoms, caution when get tattoos or body piercings, do not smoke -Get vaccinated for hepatitis (increased risk, h/o any hepatitis, or chronic liver disease) -Avoid contact with other people's blood and body fluids -Do not eat wild mushrooms -Take care with aerosol sprays -Watch what gets on your skin -Maintain healthy weight

Transcutaneous pacing

-For emergent pacing needs and used temporarily (less than 24 hrs). -Noninvasive using multipurpose electrodes: placement one anterior chest and one back between spine and left scapula. -Bridge until transvenous pacer be inserted. -Use lowest current that will cause "capture" -Patient Teaching: procedure, discomfort caused, analgesia/ sedation

Common Injuries

-Fractured ribs -Flail Chest -Pneumothorax -Hemothorax

Complications of Resuscitation

-Fractured ribs -Liver laceration -Pneumothorax -Tracheal or pharyngeal laceration -Lacerated lip or tongue -Chipped or missing teeth -Vocal cord injury -Gastric distension -Aspiration of gastric contents into lungs -Anoxic encephalopathy

Patterns of PVCs: When are they dangerous?

-Frequent -Multifocal -Two in a row -Three or more in a row -R on T: PVC falls into the vulnerable period of the T wave, Ventricular tachycardia or fibrillation can result.

Acute Endocarditis

-Healthy valves something causes them to have destruction of that valve. -Rapid progression and destruction of the infected valve.

Artificial Heart

-Heart replacement device

Management of Thoracic surgery complications

-Hemorrhage -Cardiac dysrhythmias (decreased CO) -Pulmonary edema -Atelectasis -Hypoxia -Pain -Infection -Pneumonectomy complications: empyema(collection of pus in the pleural cavity), bronchopleural fistula(fistula between the pleural space and the lung).

Complications from acute kidney injury

-Hyperkalemia -Dysrhythmias -Metabolic acidosis

Second Degree AV Block: Type II

-More severe AV block -Often associated with bundle branch block -PR interval fixed -PP interval is regular -Occasional P wave not followed by QRS ECG Characteristics: -Ventricular/Atrial Regularity: Atrial: Regular, Ventricular: may be regular or Irregular -Rate: Atrial rate: usually 60-100 beats per min; ventricular: slower than atrial rate -P waves: Normal (upright and uniform), more Ps than QRSs -PR Interval: Normal or prolonged but constant -QRS Duration: May be normal (O.04-0.10 sec), but usually wide (>0.10 sec) if the bundle branches are involved -Management: Transcutaneous pacing or transvenous pacing

CMs of thoracic aneurysm

-Most aneurysms asymptomatic until complication develops. a) Pain (constant) have constant pressure b) Dyspnea, cough c) Hoarseness of voice, dysphagia d) Rupture of aneurysm manifestations: -sudden excruciating, tearing pain radiating to shoulders, neck and upper back; may have chest and arm pain; may extend to abdomen or lower abdomen -symptoms of hypovolemic shock as a result of significant blood loss in the chest.

Management Post Cardiac Surgery

-ICU for first 24-36 hours -Hemodynamic Monitoring - Intra-arterial line, pulmonary artery line, CO/CI, SVO2 -Mediastinal/pleural chest tubes -Continuous ECG monitoring -Endotracheal tube with mechanical ventilation -Epicardial pacing wires (as needed) -Urinary catheter -NG tube (as needed) Goals: Maintain hemodynamic stability (prevent decreased CO): -Keep normotensive, adequate stroke volume, optimal preload and afterload, maintain MAP 70-80, CI 2.0-3.5 L/min/m2-inotropes, vasopressors, vasodilators, fluids -Target values - PAD 10-12 mmHg, RAP 5-10 mmHg - fluid volume -Maintain heart rate 80-100/min - intrinsic or paced Prevent complications: -Bleeding: how much chest drainage they are having anything more than 150 ml per hour is considered excessive. Risk for developing hypertension. -Graft occlusion: risk with someone who develops hypotension. -Cardiac tamponade: result of fluid collecting within that pericardial space. -Infection: going to be more delayed. Never want an infection of the sternum. -Dysrhythmias -Myocardial infarction: if not adequately perfusing coronary arteries during procedure. -Heart failure -Cardiogenic shock -Fluid and electrolyte imbalance -Acute kidney injury -Hyperglycemia: have them on an insulin drip accu-chek every hour. Get glucose back to normal limits as soon as possible. -Stroke: careful neuro assessment after procedure.

Causes of Pericarditis

-Idiopathic (unknown) most common -Micro-organisms -Viral, bacterial, fungal -Often follows a respiratory infection -Renal failure -Previous cardiac surgery -Aortic dissection -Trauma -MI -Malignancy -Lung and breast -Hodgkin's disease -Mesothelioma

Ventricular Rhythms

-Impulses initiated from lower portion of heart - Depolarization occurs, leading to abnormally wide QRS complexes -Ectopic (early) and escape (late) beats. -QRS>0.12 seconds -Polarity of T wave opposite of the QRS -No P waves -Causes: Myocardial ischemia, injury, and infarction, low potassium or magnesium, hypoxia, acid base imbalances.

Unstable Angina

-Indication of atherosclerotic plaque instability and possible thrombus formation -Chest pain at rest, intermittent, no pattern, not relieved by change in activity. -Angina warning sign of impending MI -May see ST depression or T wave inversion on ECG -Medical emergency need interventions.

Endocarditis

-Infection of inner layer of heart, the endocardium. -Forms thrombotic vegetation's on the valve (the patient's own valves) heart valves especially mitral and aortic valves.

Post Transplantation Complications

-Infection/Sepsis (bacterial, viral or fungal) -Thrombocytopenia -Bleeding -Neutropenia: reduction in white blood cell counts. -Failure to engraft: Client will die unless another transplant attempted and successful -Graft versus host disease (allogeneic transplants) - Rejection: a.Acute rejection - generally occurs in 7-30 days after transplant b. Chronic rejection - up to 100 days after transplant c. Manifestations: • Erythematous rash on palms & feet spreading to trunk (early sign) • Altered liver enzymes with liver tenderness & jaundice • GI - nausea, vomiting, anorexia, diarrhea Diagnosis: • Physical exam & site biopsies (skin, oral mucosa biopsy) Management: • Increase immunosuppression (oral or IV)

Burns

-Injury to tissues of body caused by heart, chemical, electrical current, or radiation. -Influenced by temperature of burning agent, duration of contact time, and type of tissue that is injured. Prevention strategies: -Home prevention -Outside home prevention

Silent Ischemia

-Ischemia without the client reporting pain -Individuals who may experience silent ischemia: diabetics (diabetic neuropathy), elderly, and women.

Duodenal Ulcers

-Lesion: penetrating -Location: first 1-2 cm of duodenum -Incidence: greater in men, but can occur in anyone, Peak age 35-45 years -Gastric secretion: increased -Risk factors: H. pylori most common, smoking, alcohol intake. Cms: -Pain: epigastric area, may have back pain, 2-5 hrs after meal, burning or cramping, frequently at night, some no pain or discomfort, pain relieved with antacids, food, H2 receptor blocker. -Other manifestations: if nausea, vomiting occurs, is in first few weeks to months, disappear then recur several months later.

Gastric Ulcers

-Lesion: superficial -Location: any part of the stomach (antrum most common). -Incidence: Greater in women peak age>50years -Gastric secretion: normal to decreased -Risk factors: H. pylori, medications, smoking, bile reflux Cms: -Pain: Epigastric area 1-2 hrs after meal, burning or gaseous, rarely at night if erosion, aggravated by food/eating, little or no relief with antacids. -Other manifestations: occasional weight loss.

Gastrintestinal Bleeding

-Loss of blood from the GI tract -Severity depends on origin of bleeding: venous, capillary, arterial -Life threatening GI bleed: most commonly in UGI tract (requires immediate treatment). Causes: Upper GI bleeding: -Peptic ulcer disease -Stress ulcer: SRES, Mallory-Weiss tear, Esophageal & gastric varices, neoplasm, esophagitis, aorta enteric fistula, angiodysplasia. -Acute UI bleed etiology with potential to develop hypovolemic shock. Lower GI bleeding: -Intestinal polyps -Inflammatory bowel disease -Intestinal cancer -Hemorrhoids -Trauma -Infectious colitits -Ischemia -Diverticulosis -Aortaenteric fistula -Angiodysplasia Stress Related Mucosal Damage(Stress Related Erosive Syndrome-SRES): -Acute erosive gastritis -Develops within hours of hospital adm. -Increased acid production -Decreased mucosal blood flow, ischemia -Patients at risk: mechanical ventilation, extensive burns, severe trauma, major surgery, shock, neuro disease Esophagogastric Varices: -Engorged, distended vessels of esophagus and proximal stomach -Develops as result of portal hypertension caused by hepatic cirrhosis.

Causes of Aortic Dissection

-Marfan's syndrome -Degeneration of the medial layer of aorta

CMs of acute liver failure

-Mental status changes * first clinical sign -Jaundice -Fatigue or malaise, sleepiness -Skin changes: palmar, erythema, bruises, spider nevi -Coagulation abnormalities;bleeding -Hepatic encephalopathy -Pain (abdominal) -Nausea, vomiting -Trauma: hypotension, tachycardia, tachypnea, decreased LOC, RUQ pain, guarding with rebound testing.

Premature Complex Patterns for PAC

-Pairs (coupled): Two premature beats in a row at the same time one after the other. -"Runs" or "bursts": Three or more premature beats in a row -Bigeminy: Every other beat is a premature beat - Trigeminy: Every third beat is a premature beat -Quadrigeminy: Every fourth beat is a premature beat -Aberrantly Conducted PACs: PACs associated with a wide QRS complex - aberrantly conducted (indicates conduction through ventricles is abnormal

Clinical Manifestations of Pericarditis

-Pericardial friction rub* classic sign for pericarditis grading sound or creaking sound rubbing sound when they hold their breath. -Pain: sudden, sharp, severe a) substernal, radiating to back or neck b) Aggravated by coughing, inhalation, deep breathing pain on inspiration c) Relieved to lean forward may get some relief leaning forward tri-pod position can help these patients. -Fever -Diffuse ST segment elevation and T wave inversion can lead to ECG changes see this in multiple leads and possibly all the leads. -Other manifestations: orthopnea, diaphoresis, new or worsening pericardial effusion (collection of fluid in the pericardial space this is what untreated pericarditis can lead to due to more fluid build up).

Subacute Endocarditis

-Pre-existing valve disease or damage to the valve. -Slower progression slow onset.

Second Degree AV Block: Type I (Wenckebach)

-Progressive lengthening of PR interval -Some P waves without QRSs -PR interval regular -RR interval irregular -QRS normal -Self-limiting; rarely progresses -May decrease cardiac output. ECG Characteristics: -Ventricular/Atrial Regularity: Atrial: Regular, Ventricular: Irregular -Rate: Depends on rate of underlying rhythm -P waves:Normal (upright and uniform), more Ps than QRSs -PR Interval: Progressively longer until one P wave blocked and QRS dropped -QRS Duration: May be normal (O.04-0.10 sec)

Massive Pulmonary Embolism

-Prolonged hypertension -Right sided & Left sided ventricular dysfunction -Shock &/or cardiac arrest

Surgical Care Improvement Project (SCIP) guidelines

-Prophylactic antibiotic received within 1 hour prior to surgical incision -Prophylactic antibiotic selection for surgical clients -Prophylactic antibiotic discontinued within 24 hours after surgery end time -Cardiac surgery clients with controlled 6 am postoperative blood glucose -Surgery clients with appropriate hair removal -Urinary catheter removed on postoperative day 1 or postoperative day 1 or 2 -Surgery clients with perioperative temperature management -Surgery clients on Beta Blocker therapy prior to arrival in surgery, receive a Beta Blocker during perioperative period -Surgery clients with recommended venous thromboembolism prophylaxis ordered (VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery.

Complications of Pulmonary Embolism

-Pulmonary infarction: when it creates an area that is not adequately peruse it can cause this and then lead to: alveolar necrosis that area of necrosis may become infected which could lead to abscess, pleural effusion. - Pulmonary hypertension: likely to have right ventricular hypertrophy because the heart is working harder to overcome the higher pressures in the pulmonary circulation. -Bleeding, hemorrhage because anticoagulants can increase this risk. -Heart failure both on the right side with a larger massive pulmonary embolus could develop a left sided heart failure as well, obstructive shock because you have blood flow that has been obstructed within the pulmonary circulation, death.

Ventricular Tachycardia

-Rapid, life threatening dysrhythmia -Three or more PVCs in a row -Initiated by ventricles (Monomorphic & Polymorphic) ECG Characteristics: -Ventricular Regularity: Regular (Polymorphic regular or irregular) -Ventricular Rate: 100-250 beats per minute -P waves: None or not associated with QRSs -PR Interval: None -QRS Duration: Wide (Greater than 0.10 sec), bizarre appearance -Pulseless v tach. shock then treat like V. fib. -Pulse don't shock -Pt. can have pulse or pulseless -Significant loss of cardiac output -Hypotension

Emergency Preparedness

-Recognizing changing trends in vital signs and level of consciousness is crucial -Deterioration in patient status can be: Gradual, Acute -Almost half of all patients who code exhibit warning signs up to 6 hrs prior to their arrest: -Heart rate < 45 or > 125 -Respiratory rate < 10 or > 30 -Chest pain -Altered mental status -Feeling of doom -Use the resources at the facility you work to make a difference such as the RRT

Fifth Link: Post Arrest care

-Recommended if IV access not successful after 3 attempts or takes longer than 90 sec. -Rapid infusion of colloids, crystalloids, blood products -Any drug that can be given IV, can be given IO History: -Only in children < 6 yrs. & infants -Now recommended in all ages Temporary emergency measure: -24-hour duration -Longer will increase chances of complications: Infection, hematoma, pain, fat embolus -Location - distal tibia, femur, iliac crest

Pneumothorax

-Result of severe blunt trauma or penetrating trauma -Collection of air in the pleural space. -Positive pressure in cavity causes lung to collapse and reduces alveolar gas exchange leading to hypoxemia.

Prevention of Pulmonary Embolism

-Risk assessment on admission and daily discussion to identify if they are low, moderate, or high risk and there are variations to the different risk assessment tools they may also repeat these on a daily basis. -DVT or VTE prophylaxis: (1) Sequential compression devices or compression stockings so in either case be sure they are applied appropriately. compression stockings be sure that they fit they should be optimally measured and applied carefully so that they don't create any undue pressure. (2) Early ambulation moving them turning them side to side initially getting them up into a chair and then up and ambulating as soon as possible based on whatever their current need for hospitalization is. (3) Prophylactic anticoagulation (4) Place a vena cava filter in high risk clients to try and catch the clots before they make it to the heart and lungs. (5) Early fixation of long bone fracture to try and reduce the risk for fat emboli. (6) Early diagnosis and treatment to prevent PE this is the key to DVTs. Identify and treat as quickly as possible.

Spontaneous Pneumothorax

-Rupture of blebs or air filled blisters on the lung usually located at the apex of the lungs -Primary (healthy individuals) or secondary (underlying condition such as COPD)

Hemorrhagic Stroke

-Rupture of vessel -Rupture of arteriovenous (AV) malformation Subtypes: a) Subarachnoid hemorrhage (SAH): -Caused by ruptured aneurysm or by arteriovenous (AV) malformations (mass of arteries and veins not connected with capillary network) -Risk factors: hypertension, smoking, heavy alcohol, use of sympathetic stimulants, female, h/o cerebrovascular disease or postmenopausal -Clinical manifestations SAH: (a) Sudden severe headache (b) Neck stiffness (c) Photosensitivity (d) May or may not lose consciousness -Grading scales for SAH these are the ones used not testing on these: (a) Hunt Hess Grading Scale (b) Grade I - asymptomatic or slight headache /stiffness to Grade V - comatose, posturing b)Intracerebral hemorrhage (ICH) -Caused by: hypertension, oral anticoagulation, tumors AVMs c) Intraventricular hemorrhage IVH directly bleeding into their ventricles: -ICH may extend into ventricular system -Manage BP, prevent expansion of hematoma, reverse coagulopathy, treat increased ICP

Contraindications for Pulmonary Artery Catheter

-Severe coagulation -Prosthetic heart valve a mechanical valve that has been replaced in a patient with valvular disease -Pulmonary hypertension

Management of idioventricular rhythm

-Slow rate and loss of atrial kick may result in signs of decreased cardiac output If the patient's signs and symptoms are related to the slow heart rate: -Apply a pulse oximeter -Administer supplemental oxygen, if indicated -Establish intravenous (IV) access -Obtain a 12-lead ECG -Administer IV atropine

Manage Ascites

-Sodium restriction and fluid restriction -Albumin -Diuretics (furosemide, spironolactone) -Vasopressin antagonist to manage hyponatremia - Tolvaptan (Samsca) -Paracentesis -Shunts: a)Peritoneovenous shunting: Shunt - surgical procedure to relieve ascites b) Transjugular intrahepatic portosystemic shunt (TIPS): Angiographic interventional procedure to control long term ascites & reduce variceal bleeding Post=procedure care: a) Monitor vital signs carefully and frequently for changes b) Assess breath sounds for crackles c) Administer diuretics as ordered d)Monitor for signs and symptoms hemorrhage: Screen for varices, Prevent bleeding with beta blocker (Propranolol (Inderal)), Nadolol

Functions for pacing

-Stimulates the heart to contract via myocardial cell depolarization. -Maintains primary control of pacing function of the heart.

Ischemic Stroke

-Sudden blockage of cerebral blood vessel producing area of ischemia. -Irreversible damage: infarction -Zone of tissue rounding an infarction: ischemic penumbra, ischemic tissue not irreversibly damaged Causes: -Thrombosis -Embolism -Compression or spasm of vessel Cms: -Localized to cerebral blood vessel affected (Most common - left middle cerebral artery, right middle cerebral artery and basilar artery) -Lesions in cerebral hemisphere - manifestation in contralateral side of body (side of body opposite site of stroke) -Weakness face(drooping), arm, leg; may have paralysis -Decrease sensation on one side of body -Bowel and bladder dysfunction -Incorrect perception of self and illness -Decreased sensation to pressure, heat, cold -Dizziness, ataxia, tinnitus, nausea, vomiting, difficulty with speech, difficulty with swallowing (All associated with basilar artery blockage) -Communication issues: 1) Aphasia: a) Receptive - loss of comprehension b)Expressive - loss of production of language c) Global - total inability to communicate 2) Dysphasia (left middle cerebral artery): Impaired ability to communicate 3) Dysarthria: Disturbance in the muscular control of speech -Manifestations of Right-brain and Left-brain strokes

Manage portal hypertension

-Symptom management Control bleeding: -Banding or sclerotherapy to stop bleeding of varices -Beta blockers to low systolic pressure -Sengstaken-Blakemore tube: uncontrolled bleeding

Functions for Sensing

-The ability to detect or "see" patients intrinsic heart rhythm (cardiac depolarization). -IF the rate is sufficient, the pacemaker is inhibited (ex. prevented from firing). -Sensing prevents the pacemaker from firing randomly or in competition with the heart's inherent rhythm.

Fibrinolytics (Thrombolytics

-Time is muscle; 6-hour window - best outcomes measure from the point that the mi occurred to the point of administering medication to correct the problem. -Onset of symptoms < 6 hours -Assess for contraindications [recent surgery or bleeding, presence peptic ulcer, uncontrolled hypertension, pregnancy -Less than 30 minutes from arrival Tissue plasminogen activator (t-PA) Clot specific [Alteplase (t-PA), Retaplase (r-PA), Tenectoplase (TNKase)] Non-clot specific (Streptokinase (SK) -Adjuncts Heparin and glycoprotein IIb/IIIa inhibitors Start 2-3 IVs before giving t-PA Insert any other invasive line before giving med -Complications - bleeding, increased risk for intracranial bleed

Management Torsade and V tach.

-Torsade de Pointes (V Tach): Correct cause; hypomagnesemia, hypokalemia, drugs that prolong QT interval (Quinidine, Amiodarone, Tricyclic antidepressants), congenital Long QT syndrome -Pulseless V Tach: Defibrillate, CPR, Epinephrine -V Tach with pulse: Stable but symptomatic: -Oxygen if indicated -IV access -Ventricular antiarrhythmics (Amiodarone, Sotalol, Lidocaine) Unstable: -Oxygen, IV access, sedation -Synchronized cardioversion

Management of Accelerated Idioventricular Rhythm

-Treatment usually unnecessary If the patient is symptomatic because of the loss of atrial kick: -Apply a pulse oximeter -Administer supplemental oxygen, if indicated -Establish intravenous (IV) access -Obtain a 12-lead ECG -Atropine may be ordered -Atrial pacing may be attempted

Peptic Ulcer Disease (PUD)

-Ulcer break in the lining of the mucosa of the GI tract -Have depth and involvement of the submucosa -Erosion: break in the epithelium with non depth -Result from HCL acid and pepsin (becomes proteolytic in acidic solution). Causes: -H pylori -Aspirin -NSAIDS -Stress :mechanical ventilation can lead to stress ulcers and stress ulcers can then lead to GI bleeding. Types of Ulcers: -Duodenal ulcers -Gastric Ulcers

Hypertensive Crisis

-Umbrella term used to discuss acute, severe BP elevations - Hypertensive urgency - no evidence of target organ disease (TOD) -Hypertensive emergency - Evidence of target organ disease (TOD)

Surgical Management of Aortic Aneurysm

-Utilized for aneurysm >5.0 cm in diameter or with symptoms; if ruptures, requires emergent surgical intervention -General preop management: Provide hydration; stabilize electrolytes, coagulation and hematocrit; control blood pressure

Surgical Management of Endocarditis

-Valve repair or replacement if needed to help reduce the risk of recurrence. - Complications could have an embolic events (seen most with left sided endocarditis).

Aortic Regurgitation

-Valves fail to fully: close- incomplete close -Hemodynamic effects: backward blood flow (aorta to left ventricle), increased volume load on left heart. -Sequelae: Left ventricular dilation & hypertrophy, decreased contractility, pulmonary hypertension, right ventricular failure, decreased CO. -CMs: acute (severe dyspnea, chest pain, hypotension, cardiogenic shock) Chronic (asymptomatic for years, exertional dyspnea, orthopnea, PND) -Auscultation: Diastolic murmur, S3 -Causes: acute (infective endocarditis, trauma, aortic dissection) chronic (Rheumatic heart disease, congenital bicuspid aortic valve, syphilis, chronic rheumatoid condition).

Mitral Regurgitation

-Valves fail to fully: close- incomplete closure. -Hemodynamic effects: backward flow of blood, increased volume load on left atrium and ventricle. -Sequelae: Left ventricle & Atrial dilation & hypertrophy, pulmonary congestion/edema, low CO, atrial fib. -CMs: acute (thready peripheral pulses, cool, clammy extremities), chronic (asymptomatic for years, weakness, fatigue, palpitations, progressive dyspnea, peripheral edema). -Auscultation: systolic murmur, S3 gallop. -Causes: MI, chronic rheumatic heart disease, mitral valve prolapse (MVP), Ischemic papillary dysfunction, infective endocarditis (IE).

Mitral Stenosis

-Valves fail to fully: open- incomplete open -Hemodynamic effects: decrease blood flow to (left atrium to left ventricle), incomplete, atrial emptying, increase LAP & volume, increase PAP. -Sequelae: Right ventricular hypertrophy and failure, pulmonary congestion, low CO, atrial fib. -CMs: Exertional dyspnea, fatigue, palpitations, hoarseness, hemoptysis, chest pain, seizures, stroke, atrial fib. -Auscultation: Diastolic murmur -Causes: Rheumatic heart disease (scarring of valve leaflets and chordae tendinae), Congenital Rheumatoid Arthritis, systemic lupus, erythematous.

Aortic Stenosis

-Valves fail to fully: open- incomplete open. -Hemodynamic effects: Decreased forward flow, incomplete ventricular emptying. -Sequelae: Left ventricular hypertrophy, pulmonary congestion, sudden cardiac death -CMs: Angina, syncope, exertional dyspnea. -Auscultation: Systolic murmur, S4 gallop may have S3 gallop. -Causes: Congenital, Degenerative valve disease, Rheumatic heart disease.

Clinical Manifestations of Pulmonary Embolism

-Variable: dependent on size and extent of emboli or whatever the particle is that is obstructing blood flow. Most common manifestations: can either begin slowly or have sudden onset: -Dyspnea* (sudden onset) 85% of patients will probably have this for evidence of a PE. -Pleuritic chest pain (pain on inspiration and chest wall tenderness) -Tachypnea -Tachycardia -Cough, crackles, hemoptysis Other manifestations: Anxiety, apprehension (impending doom) usually one that is more massive of a symptom, diaphoresis, fever, hypotension (could be related to lack of blood flow because of the blockage) , syncope could be related to poor perfusion to the brain, hypoxia as a result of the dead space ventilation where part of the pulmonary circulation is not participating in gas exchange so there would be more blood returning to the left side of the heart that is unoxygenated, right heart failure (JVD, decreased CO, hypotension)

CMs of Myasthenia Gravis

-Weakness and fatigue -Difficulty chewing and swallowing -Dysphagia -Ptosis -Diplopia -Weak, hoarse voice -Difficulty breathing -Diminished breath sounds -Respiratory paralysis and failure

Clinical Manifestations of Endocarditis

-Weight loss (may occur) not everybody exhibits this. -Night sweats -New or changing heart murmur*. -Other manifestations like any infectious process: Fever, chills, weakness, malaise, fatigue, confusion (elderly)rigor, symptoms of heart failure. Embolization manifestations: -Red, painful nodes in the pads of fingers and toes (Osler's nodes) -Red, painless spots on palms and soles(Janeway's lesions) -Roth's spots(retinal hemorrhages) -Petechiae -Splinter hemorrhages on nailbeds -Hematuria blood in the urine. -Ischemia/gangrene extremities -Neuro damage -Pulmonary emboli

Goal of management for acute kidney injury

1) Early identification of patients at risk 2) Maintain adequate renal perfusion and avoid renal compromise 3) Eliminate the underlying cause 4) Correct fluid imbalance -Ensure adequate intravascular volume and cardiac output -Monitor vital signs -Prerenal disease - match fluid replacement to fluid losses -Oliguric phase - may have to limit fluids to 1000 mL/day -Diuretic phase - may require 1 to 4 L of fluid per day -Accurate intake and output, assess daily weights and edema -Assess urine color, specific gravity, glucose, protein, blood & sediment -Administer diuretics when patient hypervolemic only: Loop diuretics, Osmotic diuretic (mannitol) -Renal replacement therapy (RRT): Intermittent hemodialysis, Peritoneal dialysis, Continuous renal replacement therapy, Cannulation of artery and vein 5) Prevent and correct electrolyte imbalances and acidosis: -Hyperkalemia -Hypocalcemia -Hypermagnesemia -Hyperphosphatemia -Treating acidosis: Renal failure patients often develop metabolic acidosis with mild respiratory alkalosis compensation, Administer sodium bicarbonate if serum bicarbonate <15 mEq/L, If pt. dialyzed, use dialysate with bicarbonate to help buffer 6) Prevent and treat infection: -ARF patients at high risk for infection -Must carefully select antimicrobial agents -Monitor renal function and drug levels antimicrobial agent 7) Promote improved nutritional status: -Provide adequate caloric intake and increase dietary fat -Protein intake may be decreased initially then protein needs may increase -Restrict K+, Na+ -Phosphorous may be restricted -Calcium replacement if Ca++ decreased -If unable to take oral intake, enteral feedings -Administer vitamin supplements (folic acid, pyridoxine and water-soluble vitamins frequently necessary) -Consult dietician for diet planning

Drainage Devices

1) Flutter (Heimlich) Valve: -One-way valve that allows air or drainage to collect in vented drainage bag -Used for emergency transport and for small-to moderate-sized pneumothorax -Increased patient mobility. 2) PleurX catheter can be sent home with these to drain for a period of time. Used for someone with recurring ascites -Catheter with one-way valve -May be connected to drainage system 3) Water suction drainage system: Compartments: -Collection chamber-receives fluid and air from pleural or mediastinal space -Water seal chamber-contains 2 cm of water that acts as one-way valve preventing backflow of air into the pt. (observe for bubbling air leak during inspiration) -Suction control chamber - applies suction to the chest drainage system (wet suction - sterile water) - 20 cm of suction, gentle bubbling 4) Dry suction drainage system Compartments: -Collection chamber - receives fluid and air from pleural or mediastinal space -Water seal chamber - contains 2 cm of water that acts as one-way valve preventing backflow of air into the pt. -Suction control chamber - applies suction to the chest drainage system (dry suction -no water)

Surgical Management for Cardiogenic Shock

1) IABP: Goals is increase myocardial oxygen supply and decrease myocardial oxygen demand, the IABP catheter enters into the aorta via the femoral artery. -Inflates during diastole: improves coronary systemic perfusion -Deflates during systole: decreases afterload and decreased workload of left ventricle. 2)Waveform changes with arterial pacing 3)Complications: -Limb ischemia -Aortic dissection -Bleeding -Balloon rupture -Infection -Thrombocytopenia -Catheter migration -Renal ischemia 4)Nursing management and safety: a) Actions -Assess peripheral pulses and heart sounds with the pump on standby -Monitor urine output q 1-2 hours -Zero/calibrate transducer -Flush arterial line every hour b) Safety -Do not allow IABP to remain dormant longer than few minutes means leave it moving. Going to leave it off have to take it out. -Monitor regularly for balloon rupture (brown flecks of blood in catheter) - emergency needing immediate intervention (put pump on standby, notify HCP, and prepare for removal) -Avoid flexion at groin (leg straight, knee immobilizer, log roll/tilt turn -Keep door open hear alarms -Head of bed not greater 30-degree elevation to prevent balloon migration -Monitor for poor augmentation, or gas leak alarms

Thoracentesis

1) Procedure used to drain fluid or air from the pleural space surrounding the lungs 2) Client preparation: a) Sign consent b) Time-out procedure c) Position client seated on side of bed leaning on overbed table 3) Nursing management during procedure: a) Monitor vital signs, oxygen saturation b) Monitor amount of output (excessive output >500 mL may cause hypotension) 4) Post procedure management a) Assess for relief of shortness of breath b) Assess vital signs, breath sounds c) Obtain chest x-ray d) Encourage to cough and deep breathe e) Patient discharge teaching: Wound care, Report bleeding of drainage, Report immediately to HCP (Increased heart rate, palpitations, respiratory distress, chest pain, dyspnea).

Chest tube management

1) Set up drainage unit (dry or water suction) 2) Maintain a patent, closed system: a) Tape all connections b) Secure chest tube to chest wall c) Keep tubing loosely coiled on bed (no dependent loops) d) Check frequently for kinks or loops 3) Keep drainage system below the level of chest 4) Observe the water seal: a) Check the fluid levels. b) Observe for tidaling (fluctuation in the water seal column) c) Observe for bubbling during expiration. 5) Measure drainage at least every 8 hours or more often if inserted for surgical client a) Report > 100mL/hr (>150 mL/hr with mediastinal tubes). 6) NEVER clamp the chest tube 7) Milking or stripping chest tube a) Not recommended b) Can increase intrapleural pressures and damage lungs. c) If health care provider orders - milk GENTLY! 8)Troubleshoot Chest tube and drainage system as needed a) Overturned unit - client exhale and cough b) Broken drainage system - submerge end of chest tube in sterile water and quickly replace drainage system c) Chest tube disconnected d) Chest tube pulled out accidentally cover with vent dressing or suture that area. 9) When chest tube removed, apply sterile occlusive petroleum jelly dressing

Pulmonary Gas Exchange Steps

1) Ventilation: The process of moving air between atmosphere & the lung alveoli and distributing air within the lungs to maintain appropriate concentrations of O2 and CO2 in the alveoli 2) Respiration: The process by which alveolar air gases are moved across the alveolar-capillary membrane to the pulmonary capillary bed (diffusion) 3) Transport of Gases in the Circulation: Movement of oxygen and carbon dioxide to and from the tissue cells

Chest Tube Removal

1) When lungs re-expanded and drainage minimal 2) Pre-medicate with analgesic prior to removal. 3) Tubes removed by MD or a physician's assistant 4) Valsalva maneuver during removal 5) Tie off Suture 6) Apply occlusive dressing. 7) Monitor for respiratory distress.

Abnormal Values central venous catheter

1. Decreased CVP/RAP - may indicate low volume (i.e., hypovolemia or vasodilation); Underfilled system a) Treatment may be fluid bolus and vasopressors 2. Increased CVP/RAP = increased volume, increased intrathoracic pressure or pulmonary pressures increased (i.e., tension pneumothorax, pulmonary hypertension, pericardial tamponade) a) Treatment based on cause

Post procedure for cardiac cath nursing implications

1. Assessment/Actions a. Assess frequent vital signs (q 15 min until stable), cardiac rhythm, serial 12 lead ECGs, O2 saturation b. Maintain client on flat bedrest for 2 to 6 hours; keep affected extremity immobilized/straight c. Observe catheter insertion site for bleeding or hematoma formation d. Assess for chest pain/shortness of breath e. Assess for signs of stroke (confusion, weakness, or slurred speech) f. Monitor peripheral pulses, color, temperature in the affected extremity g. Monitor urine output h. Maintain adequate oral/IV fluid intake to clear dye i. Removal of sheath with manual compression or vascular closure device for hemostasis may be used j. Administer prescribed antiplatelet medications k. Prepare for discharge (may be discharged in6-8 hours or observed for up to 24 hours) l. Monitor for complications 2. Teaching a. Maintain adequate fluid intake b. Avoid strenuous activity until HCP approves to resume normal activities; refrain from lifting over 10 pounds & straining c. Monitor cannula insertion site for bleeding d. Site care/dressing change e. Shower, no baths usually for 48-72 hours f. When to contact the HCP

Shunting

1. Blood shunted past the lung and returns un-oxygenated blood to left side of heart 2. Physiologic shunt - normally about 3% of blood returns to the left side of heart without participating in gas exchange 3. Pathologic shunt - larger amount of blood returns to left side of heart without participating in gas exchange resulting in decreased PaO2 4. Causes: AVMs, ARDS, atelectasis, pneumonia, pulmonary edema, pulmonary embolus, vascular lung tumors, intra-cardiac right to left shunts 5. Increased FiO2 does not help 6. PCO2 usually stays the same (compensation with increased respiratory rate 7. Estimation of Shunt a) PaO2/PAO2 ratio: Normal is greater than 60%, Advantage: Unaffected by changes in the FIO2, Disadvantage: requires the measurement of the alveolar PO2 b) A-a gradient 1)normal A-a gradient is<10mm Hg, with the normal gradient increasing within this range as the patient ages 2) PAO2 - PaO2 3) Alveolar to arterial pressure difference 4) Always a positive number 5)Provides an index on the efficiency the lung in equilibrating pulmonary capillary O2 & alveolar O2 6) Large A-a gradient: a) Lung is the site of the dysfunction, b)(ventilation-perfusion mismatching, shunting, diffusion abnormalities) c) PaO2/FiO2 need to know how to calculate: 1)Easily estimated measurement of gas exchange 2) Normal value is > 300 3) Lower the number, the worse the lung function 4) Use PaO2 from ABGs and FiO2 ventilator setting 5) Examples: a) PaO2 of 100, divide by FiO2 of 0.5 = 200* b) PaO2 of 85, divide by FiO2 of 1.0 = 85* *low values

Respiratory Patterns for neuro assessment

1. Cheyne-Stokes: probably the most common that you would see. 2. Central neurogenic hyperventilation 3. Apneustic breathing 4. Cluster breathing 5. Ataxic respiration 6. Kussmaul's breathing

Noninvasive Hemodynamic monitoring

1. Cuff pressures 2. Pulse oximetry

Equipment for Defibrillation

1. Defibrillator (LifePak-(used for defibrillation, synchronized cardioversion, pacing operation) or Automatic External Defibrillator (AED)): a. Key points (1) Output measured in joules or watts per second (2) Recommended energy for initial shocks in defibrillation (a) Biphasic: 120 - 200 joules 2 phases. shocks in one direction and travels back. (b) Monophasic: 360 joules Max. 1 direction pg. 265 appendix d. (3) Used for pulseless ventricular tachycardia or ventricular fibrillation (a) Immediate CPR then shock as soon as defibrillator available b. Monophasic defibrillator third picture A. (1) Delivers energy in one direction c. Biphasic defibrillator third picture B. (1) Delivers energy in two directions (2) Start with lower energy levels (3) Fewer post-shock ECG abnormalities When to use monophasic or biphasic use whichever your hospital uses. 2. Multipurpose electrodes or paddles with conductive gel pads.

Intracranial Pressure Monitoring

1. Description: a) Pressure measured using a catheter or sensor placed in one of the lateral ventricles of brain, in brain tissue or parenchyma, or in subarachnoid space b) Indications: Traumatic brain injury and GCS 8 or less, Abnormal CT scans or MRI c) Pressures: neuro patient benefits better by not having clustered care to keep their ICP low. So small clusters for these patients. -Normal ICP 5 - 15 mmHg -Abnormal if sustained more than 5 minutes > 20 mmHg -ICP > 20 mmHg = intracranial hypertension -Cerebral perfusion pressure (CPP): 1)Calculated indirect measure of cerebral blood flow 2) MAP - ICP = CPP 3)Usually maintained > 60 mmHg 4)CPP <50 causes ischemia and neuronal death -Stages of increased ICP: Stage 1: total compensation Stage 2: ↓compensation; risk for ↑ICP intervene if we could in this stage and reacting to them when you see them. Stage 3: failing compensation; clinical manifestations of ↑ICP (Cushing's triad) Stage 4: Herniation imminent → death 2. Causes of increased ICP: a) Loss of autoregulation b) Increased intracranial blood volume: Cerebral edema, mass lesion, anoxic brain injury, increased cerebral metabolism with increased CBF (seizure manage and try to prevent, hyperthermia try and keep metabolic rate down) c) Increased brain volume -Mass lesions (brain tumors, hematomas, abscesses) d) Increased amount of CSF e) Hypercapnia f) Obstruction of venous outflow: neck flexion, hyperextension, rotation g) Other: Pain, suctioning, overstimulation (don't cluster care, keep lights dim or off, limit visitation, talk quietly, tv low or off), increased intra-thoracic or intra-abdominal pressure (trendelenberg, prone, extreme hip flexion, coughing, hi levels PEEP) 3. ICP monitoring devices: a) Intraventricular catheter focus primarily on this one -Monitor ICP and drain CSF -Tip in a lateral ventricle in brain -CSF Drainage system is leveled to tragus of the ear (approximate level of foramen of Monro in brain) -Drainage of CSF is controlled by raising and lowering the drainage burette above or below the leveling point b) Intraparenchymal sensor or probe -Monitor ICP only -No external transducer, calibrated at insertion c) Subarachnoid bolt (screw) -Monitor ICP only -May be level with insertion site of bolt 4. Complications of increased ICP: a) Inadequate cerebral perfusion b) Cerebral herniation 5.Complications of CSF drainage: a) Infection b) Over-drainage of CSF: May lead to subdural hematoma c) Introduction of air into ventricular system 6. ICP Waveform: a) 3 waves, numbered P1, P2, P3 b) When second wave is largest wave, decreased intracranial compliance

Defibrillation Procedure

1. Determine need for defibrillation 2. Begin CPR while obtaining defibrillator, dry moisture off of skin, clip the hairs move hairs out of the way. 3. Setup defibrillator (a) Turn power on (b) Select energy level (monophasic vs. biphasic) (c) Confirm the sync button is turned off 4. Apply multipurpose electrodes to client's chest avoid place of pacemaker or over cardioverter defibrillator as well. (a) If paddles are utilized, place conductive gel pads on the chest and press firmly [apply 25 pounds of pressure] with paddles 5. Charge defibrillator 6. Ensure everyone is clear of bed and client 7. Deliver the electrical shock 8. Resume CPR immediately after shock it doesn't matter whether they have what appears to be a normal rhythm usually do 2 minutes or 5 cycles of CPR and then reassess

Artifact

1. Distortion of ECG tracing by electrical activity that is noncardiac in origin 2. Can mimic cardiac dysrhythmias, including ventricular fibrillation 3. Client evaluation is essential before initiating any medical interventions 4. Troubleshoot Artifact a. Assess client first b. Identify problem c. Check electrodes d. Ensure electrical equipment properly grounded

Junctional Rhythms definition

1. Dysrhythmias from the AV Junction 2.P wave changes: a. Shortened PR intervals b. No P wave c. Retrograde P waves (Inverted)

Recording ECGs

1. ECG graph made up of small and larger, heavy-lined squares 2. Horizontal axis 3. Vertical Axis 4. ECG waves, complexes, Segments, intervals. 5. Assess regularity 6. Calculate heart rate 7. Identify and examine waveforms 8. Measure intervals - PRI, QRS, QTI 9. Assess ST segment 10. Interpret ECG rhythm(s) 11. Client's clinical presentation to determine how client is tolerating the rate and rhythm

Cms of increased ICP

1. Early Manifestations (may be subtle): a) Change in level of consciousness (confusion, restlessness, lethargy, disorientation): *most sensitive & reliable indicator pts neuro status b) Headache c) Nausea or vomiting (may be projectile) usually related to higher intracranial pressures. d) Visual disturbance (diplopia) e) Difficulty following commands, motor deficits 2. Late manifestations: a) Change in vital signs (Cushing's Triad) LATE LATE LATE: -Increased systolic pressure and decreased diastolic pressure - widened pulse pressure+ main one classic sign -Bradycardia+ main one classic sign -Irregular respiratory patterns+ (late in herniation as brainstem compressed) main one classic sign -Pupillary changes: sometimes used as well. 3. Manifestations of cerebral herniation: a) Cushing's triad (uncal or tonsillar herniation) main one b) Unilateral fixed and dilated pupil (uncal herniation) main one: Ipsilateral compression of 3rd cranial nerve, Motor weakness or flexion/extensor posturing on contralateral side to side of herniation. c) Bilateral pupil dilation (central and tonsillar herniation) d) Abnormal flexion or extension (posturing) (central and tonsillar herniation) e) Positive Babinski's reflex f) Coma: not responding, not responsive to pain. g) Cingulate herniation - no specific manifestations symptoms of increased ICP decreased level of consciousness, unilateral weakness of extremities or change in pupil assessment (at risk for herniation)

Surgical Management of Peptic Ulcers

1. Endoscopic procedure: remove ulcer and/or control bleeding 2. Surgical intervention for perforation, lack of response to medical therapy, or suspected cancer. 3. Procedures: -Over sew bleeding ulcer or patch perforated ulcer -Vagotomy: severing of vagus nerve, can be total or selective -Pyloroplasty: surgical enlargement of pyloric sphincter, commonly done after vagotomy. -Gastrectomy: a. Billroth 1: gastroduodenostomy: partial gastrectomy with removal of distal two thirds of stomach and anastomosis of gastric stump to duodenum. b. Billroth II: gastrojejunostomy: partial gastrectomy with removal of distal two thirds of stomach and anastomosis of gastric stump to jejunum. 4. Postoperative Complications: -Dumping syndrome: a) Direct result of surgical removal of a large portion of stomach and pyloric sphincter b) stomach no longer has control over the amount of gastric chyme entering the small intestine. c) Occurs at end of meal or 15-30 minutes after eating d) Symptoms: weakness, sweating, palpitations, dizziness, abdominal cramps, borborygmi, urge to defecate, Last no longer than an hour e) Management: Dietary small, frequent meals; take liquids and solids at separate times -Bile reflux gastritis: a. Surgery can result in reflux alkaline gastritis: prolonged contact of bile causes damage to gastric mucosa, continuous epigastric distress that increases after meals, administer cholestyramine (Questran) -Prostprandial hypoglycemia: a) Variant of dumping syndrome b) Result of uncontrolled gastric emptying of a bolus of fluid, high in carbohydrate into small intestine c) Symptoms about 2 hours after meals d) Manifestations: sweating, weakness, mental confusion, palpitations, tachycardia & anxiety

Extubation

1. Hyperoxygenate 2. Suction 3. Deflate cuff and have client cough as remove tube so will not aspirate 4. Supplemental oxygen Nursing Assessment: -Vital signs, continuous pulse oximetry -Cardiac status -Respiratory status including rate and effort. Nursing actions: -Encourage to cough and deep breathe -Encourage use of incentive spirometer -Monitor for signs of airway obstruction: dyspnea, cyanosis, coughing, stridor, notify HCP immediately for reintubation of client. Complications following extubation: -Reintubation -Aspiration -Sore throat -Hoarsness -Airway obstruction

Clinical Manifestations of Hypertensive Crisis/ End organ damage

1. Hypertensive encephalopathy: result of increase in cerebral capillary permeability this leads to cerebral edema and disrupts the cerebral function. a) Severe Headache, nausea/vomiting, seizures, confusion, coma, blurred vision or double vision, papilledema, stroke 2. Aortic dissection simply where there is a separation between the intimal layer and the in the medial layer it is the high pressure against the wall of the aorta and especially if they have any atherosclerosis and plaque formation and may wind up being very abrasive and could lead to a dissection. 3. Renal insufficiency, acute kidney injury/ renal failure 4. Cardiac decompensation can occur very rapidly a) Unstable angina MI heart failure, pulmonary edema experience this at the same time as well. They could be experiencing chest pain and dyspnea. 5. Retinopathy the possibility of exudates and hemorrhage and papilledema a) Retinal hemorrhage

Nursing Implications for central venous catheter

1. Identify which type of CVAD in use 2. Confirm if pressure is being monitored 3. Evaluate pressures based on trend of pressures 4. Assess the client to evaluate altered pressure readings a. Other parameters to consider when evaluating fluid volume: heart rate, blood pressure, equality of peripheral pulses, urine output 5. Verify compatibilities before hanging new medication or fluid and monitor the infusion for signs of incompatability 6. Assess site for bleeding and signs of infection 7. Access CVAD per protocol 8. Utilize aseptic technique, minimize line handling, maintain occlusive dressing, perform dressing changes [usually every 7 days or prn if wet or soiled]/tubing changes/fluid changes per hospital guidelines 9. Scrub the hub 10. Change port caps 11. Draw blood or blood cultures per protocol 12. Keep lines secured and labeled 13. Maintain patency of line 14. Monitor alarms and troubleshoot if monitoring pressures 15. Report the following: dampened waveform (unable to correct), impaired circulation, catheter dislodgement, bleeding or swelling at site, signs of infection 16. Monitor for complications upon insertion and immediately after insertion, during use, and after removal 17. Removal of CVADS a. Place client supine or trendelenburg position b. Remove dressing and suture if applicable c. Have client hold breath as catheter removed d.Cover with sterile gauze and apply pressure to site e. Monitor site for bleeding, air embolism, or infection

Atrial Rhythms

1. Increased automaticity in the atria. 2. Generally, have P wave changes (Abnormal: may be flatten, notched, or lost in the QRS). -Causes: Caffeine, hypothermia, hyperthyroidism, alcohol, stress, electrolytea imbalance, hypoxia, atrial injury, dig toxicity, pericarditis

Valvular Disease Risk Factors

1. Infective endocarditis, congenital defects, degenerative changes 2. Other factors: rheumatic disease, rheumatoid arthritis, systemic lupus erythematous, Marfan's syndrome, smoking, hyperlipidemia, hypertension 3. Most commonly affected valve - aortic valve (stenosis) 4. Can affect one or more valves

Catheter insertion guidelines for Central venous catheter

1. Informed consent 2. Positioning - supine and trendelenberg (15-30 degrees) unless femoral insertion 3. Perform time-out 4. Hand hygiene, don cap, mask, sterile gown and gloves, eye protection 5. Skin prep with chlorhexidine and allow to air dry 6. Drape client using sterile technique 7. May suture catheter, apply transparent occlusive dressing 8. Verify placement with X-ray or fluoroscopy if inserted in Interventional Radiology 9. Optimal site selection (avoid femoral vein unless emergency or only access site) 10. Daily review of necessity of the line and prompt removal when unnecessary

Chest trauma clinical manifestations

1. Initially tachypnea, tachycardia, and dyspnea if it is a small area. 2. Initial ABGs respiratory alkalosis but later respiratory acidosis 3. Early signs hypoxemia: Agitation, anxiety, decreased level of consciousness 4. Shortness of breath and shallow respirations 5. Subcutaneous emphysema 6. Pain possibly chest pain may have a cough 7. Decreased or absent breath sounds over affected area clear indication of a collapse in the lung. 8. Asymmetrical chest expansion will indicate which side of the chest is involved.

4 Phases of Acute Kidney Injury

1. Initiating (onset): a) Initial insult to cell injury and decrease GFR b) Time from event to signs of decrease renal perfusion (few hours to several days; ends when manifestations appear) c) Compensatory mechanisms cause: Increase in angiotensin II, aldosterone, norepinephrine and antidiuretic hormone to preserve blood flow to essential organs. d) Decreased UOP, high specific gravity, low urine sodium e) Treatment during this phase can prevent permanent damage 2. Oliguric: a) UOP < 400 mL/day, fixed specific gravity 1.010 b) 50% of clients may not exhibit oliguria and cause delay in diagnosis and greater kidney injury c) High urine sodium level d) Urinalysis may show casts, RBCs and WBCs e) Increased BUN, Creatinine f) Electrolyte abnormalities g) Acidosis h) Fluid volume overload (decreased GFR) i) Later alterations: -Hyperphosphatemia -Hypocalcemia, -Hyponatremia -Hyperkalemia, -Serum bicarb decreased (metabolic acidosis) -Leukocytosis -BUN and creatinine increased j) Complications in this phase: fluid overload and hyperkalemia 3. Diuretic: a) Gradual return of renal function after cause of AKI corrected b) Osmotic diuresis due to high urea levels causes UOP 1-3 L to 5 L per day c) Fluid volume deficit and dehydration d) Electrolyte imbalances - hyponatremia, hypokalemia e) BUN, creatinine beginning to normalize f) If the patient receives dialysis during the oliguric phase, diuretic phase may be decreased or absent 4. Recovery: a) Begins as kidney begins to return to regular excretory function b) GFR increases to 70 - 80 % of normal c) Fluid and electrolytes normalize d) Stabilization of lab values e) Lasts 3 to 12 months f) Common some degree residual renal insufficiency and may progress to CRF

CMs of ARDS

1. Injury or Exudative - phase 1 -Interstitial edema and alveolar edema (non-cardiogenic pulmonary edema) leading to severe V/Q mismatch -Hypoxemia -Atelectasis (collapse of alveoli) -Manifestations - tachypnea, tachycardia, respiratory alkalosis, 2.Proliferative phase 2 -Hypercarbia and worsening hypoxemia, increased peak inspiratory pressures (mechanical ventilation) 3. Fibrotic Phase 3 -decreased lung compliance -worsening pulmonary hypertension -Manifestations: Decreased BP and CO, worsening hypoxemia, severe tissue hypoxia, lactic acidosis 4.Initial - subtle changes: -Dyspnea, tachypnea, cough and restlessness -Crackles -ABGs - hypoxemia and respiratory alkalosis 5. With progression: -Respiratory distress, increased work of breathing, decreased lung compliance -Tachypnea, intercostal retractions -Decreased compliance, lung volumes and functional residual capacity (FRC) noted during pulmonary function tests -Tachycardia, diaphoresis, changes in LOC, cyanosis, pallor -Crackles, Rhonchi; -Infiltrates on x-ray and may become widespread "whiteout" Altered level of consciousness, restless, anxiety, confusion

When evaluating cardiac rhythm ask theses questions

1. Is the rate fast, slow, or normal? 2. Is the rhythm regular; are complexes an equal distance from one to the next? -are the P wave to P wave distances equal throughout the strip? This is referred to as a P to P interval. - are the QRS wave to QRS wave distances equal throughout the strip? This is referred to as an R to R interval. 3. Are there P waves present? 4. Are there QRS complexes present? 5. Are there T waves present? 6. Are the intervals within normal limits (ex. PR interval, QRS interval)? 7. Is there a P wave before every QRS? 8. Is there a QRS after every P wave?

Views of the leads from ECG

1. Limb leads - use electrodes placed on: a. RA: right arm b. LA: left arm c. RL: right leg. d. LL: left leg. e. Standard Limb Leads - Leads I R arm, and L arm, II R arm and L foot, III Left arm and left foot. f. Augmented Leads - aVR R arm, L foot, Left arm, aVL left arm left foot right arm, aVF left foot, left arm, right arm A = Augmented V = Voltage R = Right arm: acts as a ground electrode. L = Left arm F = Foot

Intermediate Phase of Burns

1. Medical and Nursing Priorities: -Caring for wound: a. Hydrotherapy (cleansing the wound) b. Wound care is clean not sterile procedure c. Premedicate prior to wound care d. Prewarm room prior to wound care e. Dressing re-application f. Assess wound and healing stage as well as client's function and range of motion g. Topical Meds and Wound Dressings selection depends on wound depth, location of injury, presence of infection and provider preference h. Silver sulfadiazine, Bacitracin, Sulfamylon cream, silver sheeting products, i. Mechanical and Enzymatic Debridement: Collagenase (enzymatic cream) j. Wound Vacuum therapy -Surgical debridement and wound closure: a. Excision and grafting within 24-48 hours of admission b. Autograft - use patient's own skin from thigh or other unburned location (donor site)- Permanent c. Cultured epithelial autograft - use patients skin but sent to lab to grow into larger patches - Permanent d. Integra (artificial skin) - 2-layer man-made silicone membrane to replace dermis and covered with autograft - Permanent e. Allograft - cadaver skin - Temporary f. Xenograft - pig or bovine skin - Temporary g. Donor site care: Wound care & dressing, Manage pain, Prevent infection h. Graft site care: Maintain immobilization of graft site, Protect site from shearing, friction & pressure, Elevate extremity, Monitor for infection, Manage graft site as ordered -Pain management: a. Background pain b. Breakthrough pain c. Procedural pain d. IV pain medications tolerated e. Anxiolytics for anxiety -Ensure optimal nutrition: a. Increased calorie and protein need b. Early enteral nutrition c. Supplemental vitamins and minerals -Prevention of infection: a. Most common cause of death? sepsis b. Isolation? Contact precautions and avoidance of cross-contamination c. Handwashing d. NO prophylactic antibiotics

Medical and surgical management of Stroke and complications and treatment

1. Medical and surgical management: a) Goal - prevent and mitigate complications b) SAH - Aneurysms: -Interventions (a) Clip (b) Coiling (c) Wrap aneurysm (d) Manage BP c) Intracranial hemorrhage: -Evacuate hematoma -CSF drainage d) Anticoagulants and platelet inhibitors contraindicated 2. Complications: a) Ischemic stroke (can result from SAH) b) Cerebral vasospasm -Causes delayed ischemic neurologic deficit -Occurs between day 4 and day 14 after SAH (peak 5-9 days) -Local area of narrowing leads to local ischemia -Clinical manifestations: Changes in LOC or new focal motor weakness, Waxes and wanes -Treatment: (a) Triple H treatment - hypertension, hypervolemia, Hemodilution; achieved by vasopressors as needed, crystalloids or colloids, (b) Administer nimodipine prevent muscle spasm use this calcium channel blocker. (c) Cerebral angioplasty (narrowed vessel) c) Aneurysm rebleeding d) Hyponatremia -Syndrome of inappropriate ADH (SIADH) -Cerebral salt wasting e) Hydrocephalus: Drain CSF f) Seizures g) Systemic complications: Myocardial ischemia and infarction, left ventricular failure, ARDS 3. Diagnostic Studies: a) Non-contrast CT scan or MRI: Rule out intracranial hemorrhage b) EEG c) ECG, cardiac biomarkers d) CTA or MRA e) Cerebral angiography f) Carotid ultrasound g) Digital subtraction angiography h) Transcranial Doppler ultrasonography i) Lumbar puncture j) Cardiac imaging to evaluate any other cardiac causes to this stroke.

Nursing interventions teaching for pacemaker

1. Monitor for complications 2. Activity restrictions (arm, shoulder movement; and lifting) 3. Incision care 4. Check pulse daily and report changes to cardiologist 5. Regular follow up with cardiologist 6. Check pacemaker function regularly 7. Things to avoid medication patches over pacemaker, never put defibrillator paddles over the pacemaker, direct blows to chest, magnetic fields or high output generators such as MRI, no contact sports or heavy lifting 2 months after procedure, sexual activity pertinent information from provider, security wands from directly going over pacemaker. 8. No MRI - unless MRI safe pacemaker inserted 9. Identification card, medic alert ID or bracelet.

Troubleshooting Ventilator Alarms

1. Never shut alarms off; silence only 2. Manually ventilate if uncertain of problem until problem identified and resolved. 3. Refer to HANDOUT "Ventilator Modes and Alarms"

Patent Airway

1. Open airway: -Head tilt-chin lift methods -Jaw thrust method 2. Clear airway: suction as needed 3.Ventilate: Ambu if necessary with bag-mask-valve (BMV)/ambu bag no mouth to mouth we have to ventilate because technically a patients airway is already compromised.

Information need to perform ECG

1. Orientation of the heart 2. Conduction disturbances 3. Electrical effects of medications and electrolytes 4. Mass of cardiac muscle 5. Ischemia, injury and infarction.

Oxygenation

1. PaO2 - partial pressure of oxygen dissolved in arterial blood and reflects the body's ability to pick up oxygen from lungs. 2. Normal - 80-100 3. SaO2 - percentage of hemoglobin saturated with oxygen a) Normal 95-100% 4. Hypoxemia = PaO2 < 60 a) PaO2 <60 - intervention need 5. PaO2 < 40 - life threatening

Nursing Responsibilities for defibrillation

1. Perform procedure 2. Assess rhythm before and after defibrillation 3. Document rhythm before and after, joules used and client's response on resuscitation record

Accurate measurements for hemodynamic monitoring

1. Place reference stopcock at phlebostatic axis (leveling) 2. Tubing must be stiff, noncompliant, less than 120 cm long. 3. Calibrate routinely (zeroing) stopcock open to air etc. To allow for drift with atmospheric pressure do it once a shift. 4. Tubing free from blood and air (air embolus) 5. Confirm dynamic response (square wave testing). 6. Client position: head of bed 0-45 degrees. *note: inaccurate reading may result in inappropriate and potentially harmful interventions.

Complications of central venous catheter

1. Pneumothorax or Hemothorax 2. Air embolus 3. Occlusion 4. Phlebitis, infiltration, extravasation 5. Infection/sepsis 6. Bleeding 7. Venous thrombosis/emboli 8. Dysrhythmias 9. Mechanical complications - dislodgement, migration

3 Major categories of causes for AKI

1. Prerenal* reversible if caught early enough a) Causes: -Hypovolemia -Altered systemic vascular resistance : sepsis -Decreased cardiac output -Vascular obstruction b) Physiologic conditions that lead to decreased renal blood flow and decreased glomerular perfusion and filtration, without intrinsic damage to renal tubules c) Autoregulatory mechanisms attempt to preserve blood flow until perfusion falls below 70 mmHg d) Reabsorb Na+ and water leading to oliguria (renin-angiotensin- aldosterone system); low urine output and increased BUN and Creatinine (ratio greater than 10:1) e) If decreased perfusion persists, leads to intrarenal damage f) Reverse by treating cause and increasing renal perfusion 2. Intrarenal direct immediate damage to the kidneys: a) Causes: -Prolonged ischemia -Exposure to nephrotoxins -Contrast dye in imaging -Hemoglobin released from hemolyzed RBC -Myoglobin released from necrotic muscle cells -Inflammatory b) Physiologic conditions that damage the renal system, impairing nephron function: -Nephrotoxins cause crystallization or damage to epithelial cells -Hemoglobin and myoglobin block the tubules and cause renal vasoconstriction -Acute glomerular nephritis causes intrarenal AKI c) Acute tubular necrosis is the most common form of intrarenal failure; and is caused by ischemia, nephrotoxins, or pigments -Glomerular filtration rate decreased d) Reversible if identified early and treated appropriately 3. Post renal a) Causes: -Mechanical obstruction ureters or bladder: BPH, prostate cancer, calculi, trauma, extrarenal tumors b) Physiologic conditions that partially or completely obstruct urine flow from kidney to urethral meatus and causes reflux into renal pelvis, impairing kidney function. c) With complete obstruction, no UOP from affected kidney d) Treatment focused on removal of obstruction e) Typically, reversible if the obstruction is removed before kidney damage occurs

CMs of Cardiogenic Shock

1. Systolic BP < 90 mmHg 2. HR > 100 /min 3. Decreased sensorium 4. Cool, pale, moist (clammy) skin 5. Shortness of breath, tachypnea 6. Decreased peripheral pulses 7. Decreased bowel sounds 8. Decreased or absent urine output 9. Decreased CO/CI, increased PWP, increased RAP, decreased SVO2, increased SVR

Nursing implications for arterial catheter

1. Prior to insertion radial arterial line - Allen's test only before you put it in the line. Not after. NOT A NURSING FUNCTION just be aware to check that. (occlude radial artery... 2. Set up monitoring system prior to catheter insertion 3. Flush line, zero, test for square wave 4. Maintain continuous pressure on irrigation solution to allow slow infusion for patency 5. Prevent dislodgement and hemorrhage 6. Assess insertion site and area distal to the site 7. When line discontinued, apply pressure over and above insertion site 5-10 minutes or until bleeding has stopped. Apply pressure dressing as needed. 8. Continue to assess hemostasis maintained. Make sure the site is clean no signs of infection, no signs of bleeding etc. Diastolic notch: indicates aortic closure

Procedure for Cardioversion

1. Procedure will be nearly the same as defibrillation a. Synchronize button must be turned on b. Client sedated prior to procedure (if the client is stable) c. If client becomes pulseless, must turn off the synchronize button and perform defibrillation

Complications of Pulmonary hypertension

1. Right ventricular hypertrophy (cor-pulmonale) because of the right ventriculars need to work harder and pump blood into this higher pressure circuit so it does result in structure change of hypertrophy and we usually call that cor-pumlonale. 2. Heart failure over time all of this can lead to this.

Types of traumatic brain injury

1. Scalp: -Significant bleeding -Inspect and palpate for irregularities 2. Skull fractures: -Open or closed -Linear, nondisplaced, displaced (depressed) or comminuted -May lead to tears in dura mater, blood vessels venous sinuses -If dura damaged, CSF leaks, risk for infection, risk for cerebral herniation -Basilar skull fracture (fracture of base of skull): (1) CSF leak from ear (otorrhea) normal color clear (2) CSF leak from nose (rhinorrhea) normal color clear (3) Bruising around eyes - (Raccoon's eyes) - Late sign test these with pictures (4) Bruising behind ears - Battle's sign - Late sign test these with pictures. (5) Test for glucose if they have sinus drainage, will have glucose in cerebral spinal fluid. To test for cerebral spinal fluid that has blood in it vs. sinus drainage if it is cerebral spinal fluid and has a halo in the center than it is cerebral spinal fluid. Halo sign when blood present. Test for glucose when there is no blood present. Sinus drainage fluid will be all clustered together will not have a halo appearance. -Complications skull fractures: Infection, Hematoma, Tissue damage, CSF Leak, Seizures 3. Hematomas: -Epidural hematoma (EDH) is the worst of the two. Needs emergent care. : (1) Blood between skull and dura mater (2) Compresses or displaces brain tissue inward (3) Most common cause - arterial bleed with temporal bone fracture (disrupts middle meningeal artery: Rapid blood collection and increase in ICP, Requires prompt evacuation of blood clot and repair vessel, Manifestations: Initial loss consciousness, regain consciousness, rapidly change to unconscious, Neuro emergency -Subdural hematoma (SDH) slower process going to take longer to accumulate. Not an immediate emergency. Elderly are at greater risk for these because of them being on anticoagulants.: (1) Blood beneath dura and above arachnoid layer (2) Most often venous bleeding, can evolve to arterial bleeding (3) Management depends on the stability of the client and the manifestations (4) May defer surgery is client is stable -Traumatic subarachnoid hematoma (SAH) (see picture below) -Intracerebral (parenchymal) hematoma (ICH) 4. Contusion: -Bruise on surface of brain due to rupture of capillaries -May lead to hematoma -Risk for hematoma or cerebral edema 5. Concussion: -TBI that affects brain function -Usually caused by blow to head with brain hitting the skull. -Violent shaking head and upper body may also cause concussion -Effects are usually temporary -Brief loss of consciousness, confusion, amnesia -May have headaches and problems with concentration, memory, balance and coordination -Post-concussion syndrome: (1) Persistent headache (2) Lethargy (3) Personality and behavior changes (4) Shortened attention span, decreased short-term memory (5) Changes in intellectual ability 6. Neuronal injury: -Diffuse axonal injury (DAI): (1)Direct injury to neurons due to shearing and rotational forces that don't just impact the ..... (2) Severity depends on location and extent of neuronal injury (3) Clinical manifestations: Decreased LOC, Increased ICP, Global cerebral edema (4) May be associated with sympathetic deregulation (sympathetic storming) - episodes of tachycardia, tachypnea, hyperthermia and may be associated with spontaneous motor posturing (flexor or sensor - decortication or decerebration)) 7. Vascular injury: -Traumatic subarachnoid hemorrhage (SAH)

Uses of Central venous catheters

1. Short or long term access 2. Central Line: Administer IV fluids, blood & blood products, total parenteral nutrition, chemotherapy, other IV medications (long term antibiotics, caustic medications) 3. Measure a venous pressure in superior vena cava or right atrium (CVP or RAP monitoring) 4. Insert a transvenous pacing wire

Cms of Acute Kidney Injury

1. Signs of volume overload: Edema, pulmonary edema, SOB, heart failure, JVD, hypertension, dysrhythmias, chest pain 2. Electrolyte imbalances -Increased K+, phosphorous, BUN, Creatinine -Decreased Ca++, Na+, pH, metabolic acidosis 3. Anorexia, nausea, constipation, or diarrhea 4. Confusion, lethargy 5. Seizures or coma

Conduction System

1. Sinoatrial (SA) node: in green. Fires off impulses and spreads it from cell to cell. Normal range 60-100. Normal heart rate essentially. 2. Bachman's bundle: a super highway to get to the left atrium. 3. Internodal pathways: there's three pathways and they spread cell to cell and they depolarize and make contraction. Goes through the bachmans bundle, and to the right and left ventrical. Slows down the impulse so that they have time to fill in the atria. 4. Atrioventricular (AV) node: Slows down the impulse so that they have time to fill in the atria. 5. Bundle of His: 6. Bundle Branches: one goes to the right and one goes to the left. 7. Purkinje fibers: Finger like projections. Also have the property of automaticity and come in as a back-up to the SA node. 8. Intrinsic Rates: a. SA node = 60-100 impulses per minute b. AV node = 40-60 impulses per minute c. Ventricles (Purkinje fibers) = 20-40 impulses per minute

Complications of Spinal Cord Injuries

1. Spinal shock: -Occurs immediately after injury within minutes, lasts 24 hours to 1-6 weeks -Complete but temporary loss or depression of all or most spinal reflexes -Complication loss sympathetic tone - hypotension -Manifestations: flaccid paralysis below level of injury, absence of deep tendon reflexes, impaired proprioception, loss sensations, loss of bladder tone (retention) 2. Neurogenic shock: -Occurs with brain, cervical or thoracic injuries [T6 or higher] -Sudden loss of vasomotor tone and sympathetic innervation of heart -Manifestations: hypotension, bradycardia, body temperature instability, vasodilation -Can lead to organ dysfunction; shock contributes to hypoperfusion & secondary injury -Treatment - fluids, atropine 3. Autonomic dysreflexia: -Life threatening (occurs with injuries at or above T6) -Due to unopposed sympathetic response below the level of injury -Cause - a strong sensory input: Pain, distended bladder, rapid temperature changes, full rectum, tight clothing, GI disturbances, DVT, pressure ulcer, bladder or kidney infection, lying or sitting on hard object or minor injury -Massive uncompensated cardiovascular reaction mediated by sympathetic nervous system: SNS responds to stimulation of sensory receptors - massive vasoconstriction leading to hypertension -Manifestations: severe headache, hypertension, bradycardia, blurred vision, diaphoresis above level of injury, flushing above level of injury/pallor below injury Nursing Care: -Detect rapid increase in BP 20-40 mmHg above baseline -Elevate head, notify HCP -Identify and remove cause: 1. Check for bladder distention & immediately catheterize 2. Assess for impaction and remove if present 3. Assess for other sources of noxious stimuli - pressure constrictive clothing/tight shoes; pressure ulcers, etc. -Monitor blood pressure and heart rate closely, every 5 minutes: Short acting antihypertensive (avoid long acting antihypertensives) -Careful attention to bowel and bladder management to prevent 4. Halo Brace/Traction device complications: a. Pin site infections: Assess for signs & symptoms infection, Site care once a shift, Not use ointments or peroxide at sites b. Skin breakdown: Pressure ulcer under the vest c. Loosening or movement of pins d. Swallowing problems e. Possible dural tears f. Respiratory distress Other complications: -Paralytic ileus, neurogenic bladder, pressure ulcers, neurogenic pulmonary edema, respiratory failure, atelectasis, pneumonia, DVT/pulmonary embolism

Incications for pacing

1. Symptomatic bradycardia persistently has. 2. Severe asymptomatic bradycardia 3. AV heart block 4. Complete heart block 5. Atrial flutter/atrial fib with slow ventricular response 6. Sick sinus syndrome 7. Anti-tachycardia pacing (overdrive pacing)

Key points of cardioversion

1. Synchronized circuit delivers a shock on the R wave of the QRS of the ECG 2. Utilize low energy shock a. Initial energy lower -70-75 joules (biphasic) -100 joules (monophasic) 3. Indications for use: a. Ventricular tachycardia with pulse b. Unstable supraventricular tachycardia c. Unstable atrial fibrillation d. Unstable atrial flutter

Causes of Hypertensive Crisis

1. Untreated or uncontrolled hypertension many times its individuals that are not compliant with medication. 2. Renal dysfunction 3. Catecholamine excess a) Pheochromocytoma: tumor that causes excessive catecholamine release is a rare condition. b)MAOI in combination with other drugs or foods c)Abrupt withdrawal of antihypertensives may run out or don't have the money to do more or need a doctors appointment. 4. Pregnancy 5. Endocrine disorders (pheochromocytoma is and endocrine disorder) 6. Acute aortic dissection 7. Complication after surgery 8. Burns

RIFLE Classification of AKI

1. Use serum creatinine and/or UOP to classify AKI. 2. Risk (R) -increase serum creatinine x1.5, or decrease GFR >25% -UOP <0.5 mL/kg/hr x 6hrs 3. Injury (I) -Increase serum creatinine x2 or GFR decrease > 50% -UOP <0.5 mL/kg/hr x 12 hours 4. Failure (F) -Increase serum creatinine x3 or GFR decrease >75% -UOP <0.3 mL/kg/hr x 24 hours or anuria x 12 hours

Nursing Responsibilities for Cardioversion

1. Verify informed consent document signed 2. Verify NPO 6-12 hours before the procedure (unless client unstable) 3. Confirm baseline 12 lead ECG obtained 4. Monitor oxygen saturation and BP minimum of every 15 min. very unstable every 5 min. 5. Administer sedation as ordered 6. Check cardioverter sensing R wave appropriately 7. Document - synchronized cardioversion, rhythm before and after, medication given, joules used, client's tolerance

Complications of peptic ulcers

1.GI hemorrhage: -Erosion base of ulcer -Erosion into artery or vein -May be sudden, severe and without warning -Coffee ground emesis, loose, tarry stools -Note: tear in mucosa at gastroesophageal junction (Mallory-Weiss Tear or syndrome): results from severe vomiting or trauma or seizures. 2.Penetration into surrounding structures: small bowel, pancreas, liver, or biliary tree. 3.Perforation: -Release of GI contents into peritoneum leading to Peritonitis -Most lethal complication -Duodenal ulcers more than gastric ulcers -Manifestations: symptoms sudden onset 0-2 hrs after perforation, abd, pain radiating to back, rigid abd, rapid shallow respirations, tachycardia, absent bowel sounds. -Untreated: peritonitis within 6 to 12 hours. 4. Obstruction(Gastric Outlet Obstruction) -Result of edema, spasm or contraction of scar tissue -Manifestations: discomfort/pain worse at end of day, vomiting (often projectile), constipation -Can occur at anytime -Gradual onset -Severe obstruction: vomiting undigested food 5. Abdominal or intestinal infarction 6. Malignancy

Systematic Rhythm Interpretation

A. Assess rhythmicity - regularity (atrial and ventricular) B. Assess rate (atrial and ventricular) C. Identify and examine waveforms D. Assess intervals (PR, QRS, and QT) and examine ST segments E. Interpret the rhythm(s) F. Assess client tolerance of rhythm G. Assess clinical implication of rhythm

Management of Inhalation Injuries

A. Carbon monoxide poisoning: -Manifestations: Headache, confusion, nausea, dizziness, vomiting dyspnea, Carbon monoxide levels rise -Treatment: 100% oxygen by mask to achieve decrease carboxyhemoglobin <10% (start at scene) B. Injury above glottis: Risk for swelling -> emergent intubation C. Injury below glottis: Emergent intubation

Decerebration and decorticate

A. Decorticate response. Flexion of arms, wrists, and fingers with adduction in upper extremities. Extension, internal rotation, and plantar flexion in lower extremities. B. Decerebrate response. All four extremities in rigid extension, with hyperpronation of forearms and plantar flexion of feet. C. Decorticate response on right side of body and decerebrate response on left side of body. D. Opisthotonic posturing.

Burn Complications

A. Dysrhythmias and hypovolemic shock B. Compartment syndrome - impaired circulation, impaired ventilation C. Pneumonia, Pulmonary edema D. Respiratory Failure, ARDS E. Acute kidney injury (prerenal, intrarenal-ATN)

Escharotomies and Fasciotomies

A. Indications: -Compartment syndrome -Circumferential burns B. Priorities: -Monitor pulses hourly -Assess skin color, temperature, capillary refill C. Escharotomy: Incision through eschar and subcutaneous fat D. Fasciotomy: Incision through subcutaneous fat and muscle fascia

Phases of Burn Management

A. Prehospital Care: -Remove person from source of burn -Stop burning process -Rescuer must be protected from becoming part of incident -Airway management: Cervical spine stabilization, if applicable -Begin fluid resuscitation -Prevent hypothermia B. Emergent Phase (resuscitative): -Up to 72 hours Medical and Nursing Priorities: -Airway management: Nonrebreather mask (100% humidified O2), Early intubation & mechanical ventilation -Fluid resuscitation: Maintain tissue perfusion and organ function, Initiated with burns >20% TBSA, Fluids of choice - Lactated Ringer's. -2 large bore IVs/ central line -Parkland formula for fluid resuscitation: 4 mLs of LR per kg of body weight x TBSA, ½ the total volume is given in first 8 hours and remaining half in the next 16 hours, *may use 2mL per kg for older pts or pts with pre-existing respiratory, cardiac, and/or renal conditions, Note: electrical injury pts need higher volumes of fluid (keep UOP 75-100 mL/hr) risk of myoglobinuria -Insert foley catheter - maintain UOP at 0.5 mL/kg/hr but if myoglobin present in urine, target becomes 1 mL/kg/hr -Diuretics not indicated in this phase,If UOP drops, increase fluid intake -Baseline diagnostic studies *Key changes in emergent phase: *Dehydration, decreased blood volume *Decreased UOP (Increased BUN, Creatinine) *Hyperkalemia *Hyponatremia *Metabolic acidosis (ABGs) *Increased hematocrit -Prevent hypothermia: Increase room temperature, Cover with clean blankets -Initiation of wound care: Can be delayed several hours -Pain Management: IV narcotics, Avoid IM injections -Medications: Analgesics, Sedation, Antianxiety, Antidepressant, Anticoagulants, Nutritional support, GI prophylaxis and motility.

Calcium

A. Values: 1. Total serum calcium (8.5-10.5 mg/dL) all the calcium. 2. Ionized calcium (4.4-5.4 mg/dL) the available calcium that can be utilized. B. Actions: 1. Mediator for cardiac functions with effect on: a) Vascular tone impacts blood pressure and afterload b) Myocardial contractility how forcefully can the heart contract and how much volume can be pumped out with each contraction. c) Cardiac excitability The cells ability to generate their own impulses if they get too excited if they have that ability could occur or the ability just for the cells to normally respond to impulses coming to them from other cells. -Hypercalcemia (ionized Ca++ >5.4 mg/dL or total Ca++ > 10.5 mg/dL) -Hypocalcemia (<4.4mg/dL (ionized Ca++)

Cerebral edema for increased intracranial pressure

Abnormal accumulation of intra or extra cellular fluid. -Vasogenic: Most common Increased capillary permeability Can progress quickly to coma and death Causes: brain insults (brain tumors, abscesses, ingested toxins) Increased permeability of the blood brain barrier Treat - Osmotic diuretics (Manitol), hyperventilation or surgical decompression -Cytotoxic: Somebody who has a prolonged resuscitation. Disruption of cell membranes Causes: cerebral hypoxia or anoxia Blood brain barrier intact Treat - Osmotic diuretics, hyperventilation or surgical decompression -Interstitial: Increased pressure and volume in ventricular system Increased hydrostatic pressure associated with hydrocephalus, CSF leaks into surrounding tissue Causes: Excess CSF production, obstruction of flow, inability to reabsorb Treat - drain CSF

Conductivity

Allows cardiac tissue to transmit the impulses to neighboring connected cells. The ability to spread the impulse to a surrounding cell or a nearby cell. For ex: hot potato, all cells in the heart have this property.

Nursing Management for prehospital and emergent phase of burns

Assessment: -In ED, Primary and Secondary survey of client -Breath sounds, respiratory rate, signs inhalation injury, signs respiratory distress -Vital signs -Urine output -Pain -Anxiety -Burn wound size and depth -Assess circulation of affected extremities Actions: -Administer 100% humidified oxygen -Estimate TBSA burned -Insert 2 large bore IV accesses and begin fluid resuscitation -Cover wounds with clean, dry sheet -Institute warming measures -Implement protective isolation -Administer tetanus toxoid to all burn clients Teaching: -Explain procedures -Importance of warm environment -Risk factors to develop infection

Nursing management cardiogenic shock

Assessment: -Neuro assessment -Vital signs, hemodynamic readings, SVO2 -Skin color and temperature -Blood pressure in both arms use one with the highest pressure. -Labs: ABGs, Hct & Hgb, CMP, lactate Actions: -Provide oxygen - may require 100% O2 (non-rebreather mask) intubation with mechanical ventilation -Prepare for invasive hemodynamic monitoring -Administer medications as prescribed: inotropes, vasoactive agents, diuretics, -Administer fluids as prescribed -Restrict activity and allow periods of rest -Manage pain and anxiety -Anticipate use of assist devices Teaching: -Importance of periods of rest -Fluid and sodium restrictions as prescribed -Symptoms of heart failure to report to HCP

Nursing interventions, for aortic aneurysm

Assessment: -Neurological assessment (especially aortic arch aneurysm) -Vital signs (BP, heart rate, pulse oximetry) -Pain -Peripheral pulses, skin color, motor response -Peripheral sensation and motor response -Abdominal auscultation and palpation (gentle) Actions: -Administer prescribed medications: Antihypertensives, statins, antibiotics, stool Softners, Vasoconstrictors (hypotension) -Create calm, low stress environment -Maintain flat bedrest - legs flat Postop management: -Assess CV status, GI status, Neuro status, Resp status, Renal status, Peripheral circulation -Prevent graft occlusion - signs of occlusion: change in pulses, severe pain, cool/cold below graft, white or blue extremities -Prevent graft rupture -signs of bleeding, change in vital signs, hypovolemic shock -Assess urine output, appearance urine, BUN & creatinine -Assess for complications: MI, dysrhythmias,clot formation & embolization, renal insufficiency/acute kidney injury, colon ischemia/paralytic ileus, cerebral ischemia/stroke, spinal core ischemia -Intraabdominal hypertension (IAH): potentially lethal complication in emergency repair; associated with abdominal compartment syndrome (reduces blood flow to viscera and impairs end-organ perfusion. Teaching: -Signs and symptoms of aortic aneurysm and aortic Dissection, infection, neurovascular changes -Compliance with medications, stress reduction, and testing/screening -Gradually increase activities as prescribed -No heavy lifting -Regular screening of clients with Marfan's

Nursing Management for spinal cord injury

Assessment: -Respiratory function -Vital signs -Motor function -Sensory level -Pain -Intake and output -Surgical and /or pin sites -Bowel sounds Actions: -Maintain suction setup -Facilitate cough effectiveness -Maintain spinal immobilization and stabilization -Passive range of motion -Reposition and maintain in good alignment -Perform routine pin site care Teaching: -Signs autonomic dysreflexia -Skin care/management -Signs/symptoms respiratory distress Prevention: -Identify: 1. High-risk populations 2. Counseling 3. Education -Support legislation on seat belt use, helmets for motorcyclists/bicyclists, and child safety seats. Health Promotion in SCI: A. Education B. Counseling C. Referral to programs D. Facilitate wheelchair-accessible health care screening, exam rooms, etc.

Nursing Management for Mechanical Ventilation

Assessment: -Respiratory rate, pattern of breathing, breath sounds, ventilator settings and mode, oxygen saturation -Level of consciousness, sedation level (sedation scale) -Heart rate, blood pressure, dysrhythmias Actions: -Implement vent bundle -Monitor for complications

Nursing interventions for valvular disease

Assessment: -Vital Signs - (postop - HR, BP, CO/CI, PAP, SVO2, O2 sat) -Dysrhythmias esp. atrial fibrillation, transient or permanent heart blocks -Skin color, temperature, peripheral pulses, capillary refill -Breath sounds -Activity intolerance -Heart sounds -Click with metal valve, none with tissue valve -New onset murmur - may indicate valve malfunction or disruption of suture line -Lab values including INR -Postop complications like CABG surgery - esp. bleeding, heart failure Actions: -Optimize preload, contractility, and afterload -Increase cardiac filling pressures (PAD/PWP >18) -Fluid replacement guided by PAP and RAP/CVP -Administer medications: diuretics, calcium channel blockers, beta blockers, antibiotics, anticoagulants -Manage fluids - may require fluid restriction -Treat heart block with temporary or permanent pacemaker Teaching: -Medication information & compliance -Medic Alert bracelet recommended -Prophylactic antibiotics for dental procedures (some recommend avoid dental procedures for 6 months) -Strict adherence to anticoagulation regimen if prosthetic valve -Anticoagulation precautions: Avoid activities/sports that are high risk for injury, Report injuries or fall to HCP, Report anticoagulant use prior to any procedure -Care with shaving - electric razor preferred -Care with flossing -Limit alcohol -Dietary limitations with Coumadin -Rest and exercise guidelines -Stop smoking -Follow-up with HCP

Nursing Interventions for thoracic surgery

Assessment: -Vital signs including temperature, oxygen saturation -Respiratory status: respiratory rate, depth, trachea position, breath sounds, skin and nail bed color. -Pain (PCA pump, epidural pump, intercostal block) -Incision, chest drainage system Actions: -Administer medications as ordered: analgesics, and bronchodilators -Manage pain: splinting incision, relaxation therapy, deep breathing exercises, guided imagery. -Promote oxygenation and pulmonary hygiene: manage O2 devices/ventilator, incentive spirometry (10x hour while awake) cough and deep breathe, promote secretion removal, position client to optimize lung expansion and gas exchange (lobectomy or wedge resection positioning turn to either side [side-back-side]), pneumonectomy positioning (supine or operative side only). -Implement early activity and mobilization: range of motion on the operative side arm and shoulder, encourage use of pain control, may need physical therapy, early mobilization (up in chair, ambulation). -Manage chest tube system: pneumonectomy (usually no chest tube, if chest tube, NO SUCTION). Teaching: -Breathing exercises -Smoking cessation -Medications

Nursing Managementchest trauma

Assessment: -Vital signs, oxygen saturation -Pain -Level of consciousness -ABGs -Respiratory effort (assess status q2-4hrs & prn). -Chest tube: type, amount & color of drainage, water seal chamber (air leak), presence or absence of subcutaneous emphysema palpating around the insertion site, dressing don't routinely change the dressing. Actions: -Elevate head of bed -Encourage cough and deep breathing, turning -Encourage early ambulation -Administer prescribed medications: encourage use PCA before ambulation and pulmonary toileting. Teaching: -Use of pain medications. -Importance of coughing and deep breathing, using incentive spirometer, splint with pillow when coughing. -Motor vehicle safety: use seat belts, avoid distracted driving, no drinking and driving.

Nursing interventions: assessment, actions, teaching for Pulmonary Hypertension.

Assessment: -Vital signs: central line right atrial pressures, to be evaluated monitor HR, BP, RR and possibly right atrial pressure. -Manifestations RHF -Respiratory rate, breathing pattern -Oxygen saturation -Activity tolerance -Fluid balance -Daily weight and monitor intake and output Actions: -Administer medications as ordered -Na+ restriction to prevent fluid overload Teaching: -Progressive disorder, no cure -What to report to the health care provider -Signs and symptoms of right ventricular failure, monitor sodium and fluid intake -Medications they are being discharged on. -Activity limitations - may need handicapped parking permit, avoid temperature extremes with indoor and outdoor activities, Medic alert identifier (pulmonary arterial hypertension, other precautions) -Portable oxygen and oxygen basics -Smoking cessation -Support

Nursing Interventions for Pacemaker

Assessment: -Heart rate, blood pressure -Pacemaker spike prior to P wave (atrial pacing) -Pacemaker spike prior to QRS (ventricular pacing) -Continuous ECG monitoring for rhythm change or pacemaker malfunction. -Complications: bleeding, infection, hematoma, pneumothorax, perforation of atrial or ventricular septum -Actions -Teaching

Nursing Management for Endocarditis

Assessment: -History of drug abuse, recent dental procedure, or valve replacement surgery. -Vital signs especially temperature -Level of consciousness -Heart sounds to detect a new murmur or change -Skin assessment different nodes if those are present. -Urine output to detect the impairment if it is happening in the kidneys. Action: -Administer antibiotics as prescribed. -Refer to counseling if drug abuse is cause of IE. Teaching: -What to report to HCP signs and symptoms of infection. -Monitor temperature. -IV therapy for home health care. -Good oral hygiene with soft toothbrush since problems with the dental area could lead to infection. -Inform HCP about IE history prior to any dental or invasive procedure (prophylactic antibiotics). -Stress need for follow up care, good nutrition, early treatment of infections and to avoid infectious people. -Avoidance of stress and fatigue so that they don't risk introducing infection into their system. -Moderate activity, ROM exercise, compression stockings. -Counseling & drug rehabilitation, if appropriate.

Nursing managementfor hypertensive crisis

Assessment: -Vital signs particular focus on HR, BP, and any dysrhythmias -Pain particularly chest pain, headache -Neurologic -Renal function urine output so that we are adequately perfusing the kidneys and maintaining renal function. Actions: -Titrate IV medications to target SBP or MAP prescribed. -Administer medications as prescribed -Monitor urine output, BUN, Creatinine (better value to utilize) just tracking intake and output. -Monitor for complications-end organ damage. Teaching: -Diet: low sodium, low fat, low cholesterol targeting at least a total cholesterol < 200 and LDL < 100. -Lifestyle modification: smoking cessation, maintain ideal body weight, exercise, lowered total cholesterol & LDL, adherence to medications -Self monitoring of BP: Goal 140/90 or lower. -Warning signs of MI, CVA, aortic disease. -Medications: possible interactions with other medications or foods, importance of not stopping medication suddenly.

Nursing Interventions of Cardiogenic Shock

Assessments: -Neuro status -Vital signs -Hemodynamic parameters -Skin color and temperature -Lab tests: ABGs, SVO2, Metabolic profile, lactate Actions: -Apply nonrebreather mask (100% O2 -Anticipate intubation and mechanical ventilation -Administer fluids as prescribed -Administer medications as ordered -Restrict activity Teaching: -Importance of rest periods -Causes of cardiogenic shock and MI

Nursing Management for Septic Shock

Assessments: -Neuro status -Vital signs -Hemodynamic parameters -Urine output -Skin color and temperature -Bleeding -Laboratory values: ABG's, SvO2, ScvO2, metabolic profile, lactate Actions: -Handwashing and aseptic technique -Administer oxygen as ordered -Prepare for possible intubation and mechanical ventilation -Oral care per hospital protocol -Obtain blood cultures from 2 different sites -Administer antibiotics as ordered after cultures obtained -Administer IV fluids as ordered -Administer vasoactive drips as ordered Teaching: -Cause of sepsis -Importance of handwashing -Early warning signs

Nursing Interventions Hypovolemic Shock

Assessments: -Neuro status -Vital signs -Hemodynamic readings -Urine output -Skin color & temperature -Laboratory values: ABG's, SVO2, H&H, Metabolic profile, Lactate Actions: -Apply nonrebreather mask (100% O2 -Anticipate intubation and mechanical ventilation -Insert 2 large-bore IVs -Administer fluid replacement as ordered Teaching: -Cause of hypovolemia -Allow family visitation

Nursing Management of ARDS

Assessments: -Respiratory assessment: Crackles early, diminished later -Vital signs and continuous pulse oximetry: Increased heart rate, increased respiratory rate, decreased blood pressure -Hemodynamic monitoring: CVP/RAP or PAP monitoring -P/F ratio -Calculate and trend P/F ratio -Laboratory tests: a)ABGs (initially hypoxemia and respiratory alkalosis; later respiratory acidosis; then metabolic acidosis presents with worsening hypoxemia) b)Serum lactate (increases with anaerobic metabolism) c) Liver/Renal function tests d) Blood/ sputum cultures and CBC -Skin assessment -Renal assessment: Urine output, I&O -Chest x-ray daily: Serial - monitor for improvement/progression -Monitor and trouble shoot mechanical ventilation -Cardiac Monitoring -Dysrhythmias Actions: -Suction airway based for assessed need -Administer medications including inotropic/vasoactive agents -Patient positioning/activity: Proning, Elevate the head of the bed, Frequent position changes, Range of motion -Infection protection/ prevention: Hand washing, Central line care, UTI Bundle of care, Vent Bundle including mouth care Teaching: -Disease process -Medications -Family support -Smoking Cessation -Pulmonary rehabilitation

Nursing Interventions Anaphylactic Shock

Assessments: -Vital signs -Hemodynamic parameters -Respiratory assessment -Skin assessment Actions: -Remove trigger immediately -Oxygen with non-rebreather mask -Insert IV and administer IV fluids as ordered -Administer medications as ordered: IV epinephrine, antihistamine, corticosteroids, inhaled bronchodilator Teaching: -Cause anaphylaxis -How to administer epinephrine with EpiPen

Nursing Interventions Neurogenic Shock

Assessments: -Vital signs -Hemodynamic readings -Respiratory rate and SpO2 Actions: -Administer IV fluids as ordered -Administer IV medications -Prepare for transcutaneous pacing or transvenous pacing -Raise the head of bed slowly (risk orthostatic hypotension) -Initiate VTE prophylaxis Teaching: -If related to SCI, SCI related teaching

Idioventricular Rhythm or Vent Escape Rhythm

ECG Characteristics: -Ventricular Regularity: Regular -Ventricular Rate: 20-40 beats per minute -P waves: None -PR Interval: None -QRS Duration: Wide (Greater than 0.10 sec), bizarre appearance

Atrial Tachycardia

ECG Characteristics: -Ventricular/atrial Regularity: Regular -Ventricular/atrial Rate(s): 150-250 beats/min -P waves: Normal (upright and uniform) but differ in shape from sinus P waves -PR Interval: May be shorter than 0.12 sec -QRS Duration: 0.04 to 0.10 sec but can be aberrant at times

Causes and Risk factors for Aortic Aneurysm

Causes: 1. Atherosclerosis 2. Hypertension 3. Congenitial problems (Mafan's) 4. Other causes: syphilus (late manifestation), degenerative changes, inflammatory, infectious Risk Factors: 1. Family history 2. Advanced age 3. Male gender 4. Smoking* 5. Taking antihypertensives 6. White and Native Americans higher risk than African Americans, Hispanics, and American Asians. 7. High cholesterol 8. Obesity 9. White and Native Americans higher risk

High Pressure Alarm

Causes: a. mucous plug or increased secretions b. client biting an oral ET tube c. decreased lung compliance - pulmonary edema, pneumothorax, ARDS, pulmonary hypertension d. client anxious and fighting ventilator (breath stacking) e. Kinks in tubing f. water collecting in dependent loops of tubing g. ET tube in right mainstem bronchus h. bronchospasm Troubleshooting/Interventions: a. Suction as needed to clear secretions. b. May require bite block, notify RT c. Assess breath sounds for changes including wheezing & notify RT/MD. d. May need sedative or neuromuscular blocking agent. e. Assess tubing from ventilator to client to ensure no kinks of tubing f. Empty water from ventilator tubing. g. Check breath sounds and tube position at lip, notify RT/MD if absent breath sounds on left or tube has moved. h. Assess client, suction as needed and notify RT/MD. Bronchodilators

High Respiratory Rate

Causes: a. not tolerating weaning b. neurogenic/metabolic problem c. anxiety and/or pain Troubleshooting/Interventions: a. Assess client and notify RT/MD of findings. b. Treat neurogenic/ metabolic problems as directed. c. Reassure the client, administer antianxiety and analgesic meds prn

Central Venous catheters

Central venous pressure (CVP) or right atrial pressure. a. Central venous access devices (CVADs) b. Uses c. Normal values d. Abnormal values e. Catheter insertion guidelines f. Nursing implications g. Complications

Second Degree AV Block 2:1 Block

ECG Characteristics: -Ventricular/Atrial Regularity: Atrial: Regular, Ventricular: regular -Rate: Atrial rate: twice the ventricular rate -P waves: Normal (upright and uniform), more Ps than QRSs -PR Interval: Normal or prolonged but constant -QRS Duration: May be normal (O.04-0.10 sec), or wide (>0.10 sec)

Teaching post transplant

Detection of infection - take temperature twice a day until all immunosuppressants discontinued by HCP Prevent infection: -Avoid environmental exposure -Hygiene - daily bathing with soap & water, soft bristle toothbrush, brush with fluoride toothpaste after each meal, mouthwash as directed -Avoid direct contact with individual with infections, viruses -Handwashing with antimicrobial soap -Avoid gardening, mulching, raking, mowing, farming, or direct contact with soil & plants -Prevent respiratory infections -Prevent pet transmitted infection - minimize direct contact with animals -Water safety - drinking water, wading in water -Vaccinations -When to call: Fever > 100 for allogeneic, or 100.5 for autologous transplant

Medical Management of myasthenia gravis

Diagnosis: -Clinical assessment -Serology testing -Electromyography -Edrophonium test (Tensilon test) -CT scan Interventions: 1) Individualized to client needs 2) Symptomatic treatment to increase availability of acetylcholine 3) Immunosuppression 4) Medications: -Pyridostigmine -Neostigmine -Azathioprine, Mycophenolate mofetil, cyclophosphamide -IV immunoglobulin -Cautious use of med with MG (some antibiotics, calcium channel blockers, magnesium, antiarrhythmics, neuropschiatrics 5) Plasma pheresis 6)Surgical management: Thymectomy (will require IV neostigmine in ICU to maintain muscle strength and respiratory function) Complications: 1) Myasthenic crisis -Exacerbation of MG weakness leading to respiratory failure -Cause: respiratory infection or other infection -Clinical manifestations: weakness (esp. respiratory muscles), absent swallow and cough reflexes, tachycardia, tachypnea, hypertension, flaccid muscles, dyspnea, anoxia, cyanosis, cool, pale skin, bowel/bladder incontinence, decreased UOP. -This is an emergency - needing prompt treatment -Crisis usually last about 2 weeks -Treatment: increase anticholinesterase medication, IV immunoglobulin or plasmapheresis 2) Cholinergic crisis: -Cause: excessive anticholinesterase medication or client taking too much medication -Clinical manifestations: fasciculations (esp. facial muscles), abdominal cramps, nausea, vomiting, diarrhea, blurred vision, sweating, pallor, hypotension excessive secretions, small pupils -Treatment: withhold anticholinesterase medication, administer antidote (atropine sulfate)

Medical and surgical Management of Pheochromocytoma

Diagnosis: -Clinical presentation -Urine and plasma levels of catecholamines -Urine catecholamine metabolites (metanephrine and vanillylmandelic acid (VMA)): 24 hours urine collection, Prep for test (Teach to avoid bananas, chocolate, vanilla, and tea or coffee (even decaffeinated types)) -CT or MRI scan Medical Management: -Bedrest with head of bed elevated -Monitor for dysrhythmias -Medications: 1) Alpha-adrenergics or smooth muscle relaxants to lower BP 2) Beta Blockers 3) Calcium channel blockers Surgical management: -Adrenalectomy: 1) Preparation for surgery: Control BP and HR - treat with alpha blockers 7-10 days before surgery, Fluid management 2) Intraoperative management: At risk for hypertensive crisis - treat with nitroprusside or alpha blockers 3) Postoperative management: -Monitor BP, HR, blood glucose - at risk for hypotension, hypoglycemia -Monitor for blood loss -Measure catecholamine levels and catecholamine metabolites for several days -Bilateral adrenalectomy - will require lifelong cortisol daily

Medical Management of SIADH

Diagnosis: -Urine specific gravity: increased -Serum and urine osmolality: Serum osmolality <275, Urine osmolality increased -Electrolytes: Sodium <135 mEq/L Treatment: -Treat hyponatremia: Fluid restriction (<1000 mL/day), IV Solutions (3% saline in severe hyponatremia) but monitor closely, Diuretics to increase urine output, Demeclocycline - increases water excretion by kidneys Complications: -Decreasing sodium levels - seizures, coma -Cerebral edema, increased ICP

Medical Management of Acute Respiratory Failure

Diagnosis: 1) ABGs 2) Oxygen saturation - target >90% (Closely monitor COPD clients) 3)Hematocrit & hemoglobin (binding sites for oxygen) 4)Testing specific to identify underlying cause: -Chest x-ray -Sputum cultures 5) V/Q (ventilation to perfusion) lung scan Prevention is the best way to prevent complications of respiratory failure.: 1) Identify at-risk patients 2)Teach deep breathing and coughing; use of incentive spirometry; activity (ambulation) 3)Hydration and nutrition 4)Early recognition of respiratory distress Treatment: 1)Not a disease but a condition 2)Result of one or more diseases involving the lungs or other body systems 3)Must treat the respiratory failure as well as the underlying cause 4) Improve oxygenation a) Correct hypoxemia delivery system should: -Be tolerated by the patient -Maintain Pao2 60 mm Hg or more and Sao2 at 90% or more at the lowest O2 concentration possible -BNC, venturi mask, nonrebreather mask -Non-invasive positive pressure ventilation (NPPV), BiPAP, CPAP -Intubation and mechanical ventilation and PEEP b) Improve ventilation: Mobilization of secretions -Hydration and humidification can use aerosol agents to help humidify. -Chest physiotherapy*: Postural drainage, percussion, vibration -Airway management and suctioning, Nasopharyngeal, oropharyngeal, nasotracheal -Effective coughing and positioning -Positive pressure ventilation: BiPAP, CPAP, Mechanical Ventilation, PEEP.

Medical Management of GBS

Diagnosis: 1) Lumbar puncture (elevated protein and normal cell count) 2) Electromyography (slowed nerve conduction as develops paralysis) Treatment: 1) Supportive care and reduce the severity, potential complications, suffering, recovery time 2) Medications: -IV immunoglobulin -Steroids?? 3) Plasmapheresis 4) Diet -Enteral feedings -Individualized feedings to meet client needs Complications: 1) Respiratory failure 2) Complications of immobility

Medical Management for Spinal cord injuries

Diagnosis: 1. Physical exam and reflex testing 2. Cervical, thoracic and lumbar x-rays 3. CT scan or MRI Treatment: 1. Acute stage of injury (Initial care): -Ensure patent airway -Stabilize cervical spine -Administer oxygen -Establish IV access -Assess for other injuries -Control external bleeding -Obtain imaging -Prepare for spinal immobilization with tongs/traction -Manage pain:Musculoskeletal pain (opiates, muscle relaxants), Neuropathic pain (antidepressants, anticonvulsants) -Ongoing monitoring: VS, LOC, O2 sat, cardiac rhythm, urine output, Keep warm., Monitor for urinary retention, Monitor for hypertension, Anticipate need for intubation if no gag reflex. -Once stabilized: Continuous monitoring, Obtain history of incident, Thorough assessment, Muscle groups, Sensory exam, Associated brain injury Medications and Fluid Management: 1. Atropine (for bradycardia), if not responsive - pacemaker 2. Vasoactive and inotropic meds: Dopamine, epinephrine, norepinephrine, phenylephrine, dobutamine, vasopressin 3. Steroids?? may give them may not if they do give them it is to reduce swelling. 4. Fluids (crystalloids, colloids) - fluid resuscitation 5.Muscle relaxants = Baclofen & Dantrolene 6.Stool softeners, bulk laxatives - Colace, Miralax Immobilization & stabilization: 1. Stabilize and decompress injured spinal segment: -Eliminate damaging motion. -Prevent secondary damage. -Maintain neutral position. -Stabilize to prevent lateral rotation. -Blanket or towel -Hard cervical collar -Backboard (temporary) -Keep body correctly aligned. -Log roll 2. Traction or realignment: -Pin site care), Halo traction device have screwdriver or wrench with you in case need to do CPR. -Meticulous skin care critical with all types of immobilization

Medical management of MS

Diagnosis: 1. Rule out other disorders: Test for other inflammatory or infectious diseases 2. History and neuro exam 3. Lumbar puncture: CSF (check for WBC's, proteins, rule out viral infections) 4. CT or MRI to identify any lesion of brain 5. EPS studies 6. Evoked nerve potentials Medical management: 1. No cure for MS 2. Enhance recovery from attacks, reduce number of attacks, slow disease progression 3. Life style management (adequate rest, exercise, staying cool, eating healthy/well balanced diet, relieve stress) 4. Medications: a. Beta interferons (slow disease progression) b. Corticosteriods and plasma exchange (decrease inflammatory and immunologic factors) c. Treat clinical manifestations -Muscle relaxants (baclofen) decrease spasticity -Physical therapy to strengthen muscles -Anticonvulsants -Stool softeners, laxatives Complications: a. Muscle stiffness or spasms b. Paralysis (legs) c. Bladder, bowel and sexual function problems d. Mental status changes e. Depression f. Seizures

Medical Management of Diabetes Insipidus

Diagnosis: 1. Serum and urine electrolytes -Increased sodium >145, normal urine sodium -BUN and Creatinine increased 2. Serum and urine osmolality: Serum osmolality >295 mOsm/kg, decreased urine osmolality <200 mOsm/kg 3. Urine specific gravity: low urine specific gravity (1.001-1.005) 4. CT or MRI of head 5. Water deprivation test -All water withheld -Urine osmolality and body weight measured hourly -Normal test - urine osmolality 2-4 times greater than serum osmolality - DI - serum osmolality increases but no change in urine osmolality Medical management: 1. Maintain adequate fluid status -Unconscious client: Replace water with hypotonic solution (DsW), Monitor for hyperglycemia, volume overload, correction of hypernatremia -Conscious client: Awake, alert client can drink to replace water losses 2. Desmopressin (DDAVP) -Medication of choice for DI -Routes - subcutaneous, intranasal, and oral -Monitor frequently - fluid status, serum electrolytes, and urine output Complications: -Dehydration -Hypovolemia -Hypernatremia: Confusion, neuromuscular excitability, seizures or coma

Medical management for chronic liver failure

Diagnosis: Lab testing: -AST, ALT, Alkaline phosphatase - all elevated -Serum bilirubin (total and direct) - elevated -Albumin - decreased -Ammonia - elevated -Coagulation studies - prolonged PT, aPTT and INR, thrombocytopenia Diagnostic testing: -Ultrasound, CT scan -Esophagogastroduodenoscopy (EGD) -Endoscopic retrograde cholangiopancreatography (ECRP) -Angiography -Liver biopsy: Percutaneous of needle biopsy, laparoscopic or open biopsy, or transverse biopsy, performed to obtain sample of liver for examination to look for signs of damage or disease. -Paracentesis (ascitic fluid removal): remove ascitic fluid in peritoneal cavity, associated interventions (have patient void immediately before, position in high fowler's or sitting on side of bed, assess vital signs during and after procedure, monitor for fluid and electrolyte imbalances, administer colloids as ordered to replace proteins, monitor dressing for bleeding/leakage, analysis of ascitic fluid). Management Goal: -Slow progression of cirrhosis and prevent complications: rest, administration of B-complex vitamins, avoidance of alcohol, aspirin, acetaminophen and NSAIDs

Medical management for acute liver failure

Diagnosis: Diagnostic testing: -Serum bilirubin increased -Protime prolonged -Liver enzymes; increased ALT, AST -Glucose: hypoglycemia -Ammonia levels increased -Other diagnostic: albumin levels, CBC, drug and toxin screens, viral hepatitis serologies -CT or MRI Goal management: -Decrease ammonia levels: neomycin, lactulose, decrease protein intake -Maintain hemodynamic stability -Prevent bleeding -Prevent infection -Protect from injury -Prepare for transplant if liver failure cannot be reversed -Provide comfort -Prevent and assess for complications Hepatic encephalopathy staging based on assess the patient: - stage 1 euphoria, or depression, mild confusion, slurred speech, disordered sleep rhythm, slight asterixis (flapping tremors movement of their hands), normal EEG - stage 2 lethargy, moderate confusion, marked asterixis, and abnormal speech - stage 3 marked confusion, incoherent speech, sleeping but arousable, asterixis, abnormal EEG - stage 4: coma, unresponsive to painful stimuli, asterixis absent, abnormal EEG Diet: -Decreased protein intake Medications: -Medications to reverse poisoning (From acetaminophen or mushrooms) -Osmotic diuretics -Benzodiazepines -Propofol Complications: -Bleeding -Increased intracranial pressure -Infection

Medical Management of Pancreatitis Diagnosis and lab tests, imaging, severity scoring

Diagnosis: Physical exam: -Tender abdomen, localized guarding and rebound tenderness. -Cullen's sign: when you get bruising somewhere around the umbilicus. -Grey Turner's sign: have bruising that occurs in the flanks or sides. Lab Testing: -Metabolic panel (especially Creatinine, BUN), serum sodium, potassium, magnesium, and calcium decreased, glucose increased, elevated BUN. -Hematology studies -Pancreatic enzymes (amylase, lipase): serum amylase and lipase levels increased. -Liver enzymes (AST, ALT, ALP and LDH), serum bilirubin: AST, ALT, bilirubin increased in gall stone pancreatitis. -WBC -Triglyceride levels increased -Urine amylase increased -C-reactive protein increased Diagnostic imaging: -Abdominal CT -Abdominal MRI -Abdominal ultrasound -Endoscopic retrograde cholangiopancreatography (ECRP) Pancreatic severity scoring: -Ransom's criteria: measure of severity of illness and risk of mortality. -APACHE II score: evaluating severity but is not limited to just pancreatitis can be used on other types of issues. -Balthazar CT severity index.

Management of Pulmonary Embolism

Diagnostic and Laboratory Studies: Imaging: -12 lead ECG - may see non-specific inverted T waves and ST changes based on the changes in the chamber on the right ventricle and eventually maybe possibly into the left ventricle will always be using it to rule out that they are having a PE and not an MI. -*CT scan - spiral (helical) CT scan with contrast it circles around and can better select large and small pulmonary emboli. -Ventilation-perfusion scan (V/Q scan) in individuals who cannot have a cat scan. -Pulmonary angiography (most definitive) allows us to study the blood vessels and identify where areas of blood flow(1) have been obstructed. So this is probably the Gold standard where it would absolutely confirm the diagnosis but again it is invasive and tends to be avoided if we can others to try and identfy the diagnosis least invasively -Ultrasound (lower extremity) to try and identify the source if they think it was a thrombus from a DVT. Laboratory: -D-dimer level (positive D-dimer - indicates clot in body) measures the amount of cross linked fibrin fragments so these fragments then would be the result of clots being broken down or degraded and would not expect to find in a healthy individual unless there were clots found somewhere in the body. It can be a disadvantage because this test is nonspecific it's not going to help you locate specifically where the clots are. If they have small infarcts it might even miss some of those because they are too small. If had somebody suspected of pulmonary emboli, then they would check this and if it was elevated but normal venous ultrasound they would still possibly need a cat scan or lung scan to confirm diagnosis. If the d dimer was positive test would be indicating that you have these cross linked fibrin fragments indicating that there are clots that are being broken down. If it was negative, then it could be a false negative there could be small clots there that it is not picking up and not picking up those changes. -Arterial blood gases (ABGs) would be used to assess the level of hypoxemia and then use that to assess their acid base imbalance initially if they are breathing rapidly they could have respiratory alkalosis as they blow off the excess CO2 and later may develop metabolic acidosis as they change to anaerobic metabolism. -BNP (elevated - strain on ventricles) would be utilized to evaluate the right ventricular strain and possibly eventually into the left ventricular activity so we can get elevations when the left or right ventricle are working harder. -Troponin (transient increase) this could be related to alterations in the ventricles or some area with ischemia because we could not be adequately perfusing the myocardium itself.

Management of Pulmonary Hypertension

Diagnostic and Laboratory studies: -Ventilation/perfusion scan to evaluate the degree of mismatch that they have. -Chest CT/Spiral CT to evaluate the lungs itself and try to rule out any other pulmonary diseases. -Right heart catheterization* this would be probably the best way to get at those pressures because we don't expect a pulmonary artery catheter placed. -Pulmonary function tests help rule out other diseases that might cause SOB. -Vasoactivity Test given vasodilators in the cath lab and noting whether the vessels in the lungs respond or not to the vasodilators. -Echocardiogram gonna give them information about whether they have valvular heart disease, the structures of the ventricle and whether there is any dysfunction on either side left or right ventricle, might identify any shunts that might be present in the heart itself. -Chest x-ray might see an enlarged heart shadows particularly the right ventricle might see changes there. -12 Lead ECG: might be able to pick up the right ventricular strain or hypertrophy but also with the chest pain we would be trying to determine if they are also having an MI. -Pulmonary angiography would help us rule out any thromboembolism. -6-minute walk test keep track of how much distance they cover to help evaluate their response to exercise and their tolerance towards it since this is a chronic disease. -Serology tests looking for anti-nuclear antibodies. -Sleep study to pick up any signs of sleep apnea.

Complications with Sepsis

Disseminated Intravascular Coagulopathy (DIC): • Initial thrombotic (clotting) stage and then bleeding stage • DIC Risk Factors: -Shock -Septicemia: Gram-negative sepsis, meningococcemia, malaria, histoplasmosis, aspergillosis -Hemolytic processes: Transfusion mismatched blood, acute hemolysis -Obstetric conditions: Septic abortion, toxemia, abruptio placenta, retained dead fetus -Malignancies: Prostate, pancreas, lung, stomach, leukemia -Tissue damage: Burns, trauma, extensive surgery, head injury, leakage of abdominal contents • Clinical Manifestations: -Clotting stage: Clots in microvasculature producing ischemia and necrosis, Cyanosis and ischemia in fingers and toes, tip of nose, Organ ischemia (r/f DVT, PE, CVA) -Bleeding stage: Excessive breakdown of clots, Increased levels fibrin degradation split products, Increased D-dimer, Decreased platelets, Prolonged PT aPTT • Management: -Volume replacement with crystalloids (NS, Blood, clotting factors, FFP, platelets) -Identify and treat cause -Treat if present: hypotension, hypoxemia, respiratory distress, metabolic acidosis Nursing interventions: -Assess mental status, UOP, vital signs, hemodynamic, O2 sat, lab values -Assess for bleeding • Prevent bleeding: Venipunctures or injections, Non-invasive BP, Low suction with suctioning, Skin care, specialty bed -Assess for petechiae, ecchymosis -Assess for organ dysfunction Multiple Organ Dysfunction Syndrome (MODS): • Progressive failure of 2 or more organs • Lungs (usually first to show symptoms) -> ARDS • Renal System - Renal failure • Hepatic System - Liver failure • GI System: Ischemia to bowel • Cardiac System - HF • Management: -Supportive: Control infection, Maximize oxygenation, Restore and maintain fluid volume, Nutritional support

Nursing assessment for airways

ETT - endotracheal tube: -Tube type - ETT (oral or nasal) -Size of airway -Location at teeth, gums (marking on tube) -Cuff pressure (pilot balloon) -Assess for mucosal damage -Check for stability/securement -Ventilator settings Trach - tracheostomy: -Tube type and size -Cuff pressure (pilot balloon) -Assess insertion site/stoma Check for stability/securement -Ventilator settings ABGs, SpO2, signs of hypoxemia. Respiratory rate, rhythm, work of breathing, use of accessory muscles.

CMs of Acute Respiratory Failure

Early: -Dyspnea can also have mental status change might see if you know the person. -Restlessness -Anxiety -Fatigue -Increased BP -Tachycardia Intermediate as they progress into respiratory failure.: -Confusion -Lethargy -Pink skin color Late of respiratory failure: -Cyanosis LATE sign LATE SIGN -Coma LATE SIGN or respiratory failure Will also present with symptoms of underlying cause or disease process.

ECG Electrocardiogram

Electrodes placed on the wrists, ankles, and six locations around the chest produce a comprehensive picture of the cardiac electrical activity. The principal waveforms produced are the O wave, QRS complex, and T wave. The principal segments include the PR segment, and the ST segment. The intervals include the PR interval, QRS interval, and QT interval.

Medical Management Hypertensive Crisis

Goal will be to lower the MAP but not too rapidly. 1. Emergently lower the MAP no more than 25% in the first 2 hours or to 160/100 mmHg: will depend on how high the pressure is for the patient. 2. Determine the cause of the HTN crisis and treat cause to prevent further damage to other organs. 3. Immediately detect end organ involvement and prevent/minimize further impairment. Getting BP down will be a key component to this. 4. Hospitalization and most likely into the ICU area.

Goal management of acute pancreatitis

Goal: -Manage/relieve pain -Prevent pancreatic stimulation -decreased pancreatic secretions -Manage hypovolemia and electrolyte imbalance -Prevent/treat local complications -Prevent/treat organ failure Manage/relieve pain: -Priority to treat as pain increases enzyme release -Position to decrease pain intensity: knee to chest, side lying with head elevated 45 degrees -Change position frequently Prevent pancreatic stimulation: -NPO status, NG suction until no abdominal pain and serum amylase normal. Manage hypovolemia and electrolyte imbalance: -Aggressive fluid resuscitation: initial infusion of IV fluids several liters initially, then 200-300 ml/hr (lactated ringer's or normal saline); plasma expanders (dextran, albumin), RBCs (caution to avoid over hydration), high dose FFP to replace proteins. Manage shock/hypotension: -May require vasoactive med: dopamine. Monitor and restore electrolyte balance: -Hypocalcemia -Assess for tetany, Chvostek and trousseau signs -Hypomagnesemia -Decreased sodium, potassium levels -Monitor serum glucose levels: accuchek. Prevent/treat local complications of pancreatitis: -Prevent infection -Antibiotics prophylactically -Percutaneous or stent therapies to drain fluids in and around pancreas -Surgical resection of debridement -Removal of gall stones (Biliary ERCP and laparoscopic cholecystectomy) Prevent/treat organ failure: -Administer O2 to maintain SaO2: manage respiratory failure/mechanical ventilation -Support myocardial contractility: dobutamine infusion -Prevent infection: monitor for clinical manifestations of sepsis -Manage coagulopathies -Treat renal failure

Medical Management of traumatic Brain injury

Goals: -Minimize damage -Manage intracranial pressure in optimal range -Promote cerebral perfusion Emergency management: 1) Ensure Airway: GCS 8 or less - intubate with mechanical vent 2) Stabilize cervical spine 3) Breathing pattern: Hypoxic -> give oxygen 4) Circulation - vital signs (BP, HR, R, O2 sat, GCS) 5) IV access - 2 large bore IV's and infuse NS or RL 6) Control external bleeding - pressure dressing 7) Assess for otorrhea, rhinorrhea, scalp wounds 8) Remove client's clothing and assess for other injuries 9) Maintain client warmth 10) Ongoing monitoring 11) Administer fluids cautiously 12) Prevent secondary injury - treat cerebral edema Diagnosis: -CT scan usually done without contrast because we want to see if there is any bleeding and the contrast could alter that result. -Cervical spine x-ray -Transcranial Doppler studies (indirect measure CBF) -Laboratory studies: a) Serum electrolytes especially sodium b) CBC c) Coagulation studies d) Serum osmolality e) CSF examination -Management of increased ICP

Management of Chest trauma

Imaging Studies: -Chest x-ray primary one to be done presence of air or fluid in that pleural space as well as a decrease in that lung volume. Amy other mediastinal damage as well. -Ultrasonography will help them rule out cardiac tamponade. -Chest CT if they have abnormal chest x ray may use this to see what else could be going on. For high impact trauma. Laboratory Studies: -ABGs to respiratory alkalosis due to increase respiratory rate and later to acidosis when they start changing in CO2 also may have hypoxemia see a decrease PO2 and decrease O2 sat . -Serum lactate adequacy of oxygen reaching to the tissues. Lactic acidosis when lactic acid is high. -Hemoglobin, hematocrit -CBC, CMP, Coagulation studies, type & crossmatch for possible blood transfusion

Nursing Management for Diabetes Insipidus

Interventions: Assessment: -Vital signs -Daily weight -I&O -Visual acuity -Serum sodium and osmolality -Urine specific gravity Actions: -Administer desmopressin or vasopressin as prescribed -Maintain IV and prescribed IV fluids (decreased LOC) -Provide adequate oral intake (alert/oriented client) -Provide mouth care Teaching: -Weigh daily at same time on same scales -Clinical manifestations of DI -Clinical manifestations of fluid overload -Importance of taking medications (ADH replacements) as ordered

Nursing Management of Myasthenia Gravis

Interventions: Assessment: -Breath sounds -Respiratory effort -Vital capacity measurement -Nutritional intake, I&O, daily weight -Dysarthria -Dysphagia Actions: -Administer medications at prescribed times and prior to activities requiring swallowing -Elevate the head of the bed for eating or drinking -Establish method to communicate -Plan meals when medications at peak levels -Offer soft foods and thickened liquids -Plan for rest periods between activities of daily living Teaching: -Importance of taking meds as prescribed -Educate to carry meds with client at all times -Medic alert bracelet -Avoid public places in winter (risk for flu/infections) -Obtain vaccines to prevent flu and pneumonia -Prevent fatigue with frequent rest periods -Do not take over-the-counters meds without checking with HCP -Educate client and family about disease process -Inform of resources available

Nursing Management for Stroke

Interventions: Assessment: -Neuro assessment every 1-2 hours -Vital signs every 1-2 hours or more often: Increase frequency with IV rt-PA per protocol for 24 hours -ECG and cardiac enzymes -Serum electrolytes especially sodium -I&O, fluid balance Actions: a) Administer rt-PA as ordered b) Perform bedside swallow screening before taking any fluids or eating. c) Elevate HOB 30 degrees d) Place NG tube of feeding tube for nutrition and medication administration e) Implement aspiration precautions f) Bleeding precautions for clients receiving thrombolytics or anticoagulants g) Frequent repositioning, elevate paralyzed or weak extremities h) Obtain PT and OT evaluations early: i) Aphasia Interventions -Provide repetitive directions -Break tasks down to one step at a time -Repeat names of objects frequently used -Allow time for patient to communicate -Use picture board, communication board or computer technology j) Implement SAH precautions (preop)if applicable -BP control -ICP monitor and management -Bedrest -Dark quiet environment -Stool softeners so they are not straining. -No restraints, keep calm -HOB increased 30 degrees at all times Teaching: -BP control -Stroke diagnosis -Activation of EMS -Warning signs and symptoms stroke -Client specific and family specific risk factors for Stroke -Smoking cessation -Medications for prevention of stroke -"FAST" quick assessment to determine if they have a warning sign. F facial drooping or numbness, A arm weakness, S Speech difficulty (slurred, mumbled), T time to call 911. Rehabilitation/Home Care: -Optimize motor, sensory and cognitive functions -Secondary stroke prevention -Psychosocial needs -Musculoskeletal functions: Training, Assistive devices -Toileting interventions: Bowel Program, Nutrition

Nursing Management for cranial surgery

Interventions: Assessment: -Neuro assessment q1-2 hours immediately postop up to 48 hours -Vital signs -Fluid and electrolytes, serum osmolality -Assess dressing color, amount of drainage and odor -Assess for bleeding Actions: -Same as care with increased ICP (a) Avoid any potential causes of increased ICP (b) If Ventriculostomy, ICP monitoring and associated care -If bone flap removed, do not position on operative side -Provide incision care after dressing removed -Turn and position depending on site of procedure: Head of bed 30 degrees -Posterior fossa or burr hole, keep flat or up to 10 degrees elevation -Provide enteral nutrition -Administer medications as ordered -Prevent injuries (corneal abrasions, periorbital edema saline drops) -Management CSF leak (dressing, testing) -Avoid nasogastric tube if CSF leak -Implement seizure precautions -Implement VTE prophylaxis Teaching: -Medications (tapering steroids, antiepileptics) -Monitoring glucose -Preventing falls -Wear hat or head covering as needed -Increasing independence -Promote optimal functions (careful positioning, skin care, mouth care, range of motion exercises, bowel and bladder care and adequate nutrition) -Referrals (speech therapist, physical therapist)

Nursing Management of SIADH

Interventions: Assessment: -Neurological assessment -I&O -Serum sodium and osmolality -Urine specific gravity and urine osmolality -Skin integrity Actions: -Restrict fluids -Administer demeclocycline as prescribed -Administer 3% saline as ordered via central line -Seizure precautions Teaching: -Disease process and management -Follow fluid restriction -Signs of fluid overload

Nursing Management for Peptic Ulcers

Interventions: Assessment: -Vital signs -Abdominal assessment -gastric pH if ordered -Presence of occult blood (emesis and stool) -Alcohol and other medications use (ASA, NSAIDS) -CBC, electrolytes, and BUN -Pain -Diet, symptoms (anorexia, fullness, nausea, vomiting of symptoms of dumping syndrome) - I&O and daily weight -Complications Actions: -Provide regular mouth care -Limit food intake after the evening meal, eliminate bedtime snacks -Administer prescribed medication therapy -Maintain IV infusions and administer blood products as ordered -Assist with gastric lavage as indicated for GI bleeding -Prepare client for diagnostic procedures or surgery Actions complications: a. Hemorrhage -Assess changes in vital signs, increase amount and blood in aspirate -Perform pain assessment -Maintain patency of NGT b. Perforation -Check vital signs every 15-30 minutes. -Assess bowel sounds -Stop all oral fluids and food, NG feedings, medications, notify HCP -Replace volume lost with IV fluids (central line) -Administer antibiotics as ordered -Prepare for surgical closure c. Obstruction -NGT -Monitor for distress or vomiting as resume oral intake -Manage fluid and electrolyte imbalances d. Relieve pyloric obstruction though endoscopy or surgical intervention. Actions Postoperative care: a. Like postop care after abd laparotomy: -Assess vital signs at least q4hrs and prn -Manage NG tube do not reposition or remove without order -Monitor bowel sounds immediately post op don't expect to hear bowel sounds. -I&O -Change client position at least every 2 hrs. Teaching: -Avoid risk factors including overuse of ASA and NSAIDS, spicy foods,caffeinated beverages. -Medications: take as prescribed -Avoid eating within 2 hrs of bedtime -Teaching for postoperative clients. -Advise to reduce drinking fluid (4 oz) with meals -Diet: small, dry feedings;low carbohydrates; restrict sugar with meals; moderate amounts of protein and fat -Rest for 30 minutes after each meal -Take vitamin and mineral supplements -Health promotion and prevention -Identify clients at risk -Provide early detection and treatment -Encourage clients to take ulcergernic meds with food or milk. -Report symptoms related to gastric irritation to HCP: nausea, vomiting, epigastric pain, bloody emesis, or tarry stools.

Nursing Management for Intermediate phase

Interventions: Assessment: -Vital signs -Daily weight -Daily Caloric Care -Total protein and albumin levels -White blood cell counts -Wounds for signs of healing and clinical manifestations -Pain and anxiety Actions: -Involve patient in plan of care -Give pain medication on scheduled basis instead of prn -Utilize non-pharmacologic pain relief techniques -Calorie counts and encourage oral intake -Daily wound care -Facial care, eye care for corneal burns -Hands and arms extended and elevated on pillows or slings -Ears kept free of pressure -Gastric decompression with NGT -Perineal care - foley catheter -Assist with ADLs and compliance with rehabilitations exercises -Administer medications prescribed - GI prophylaxis Teaching: -Instruct patient to request additional pain medication when needed and not to delay until pain is intense -Provide information to patient and family about progression of wound healing -Develop a rehab plan -Educate on importance of nutrition and diet plan

Nursing Management for TPH

Interventions: Assessment: -Vital signs -Neuro assessment including vision disturbances -Intake and output, daily weight, mucus membranes and mouth -Serum sodium, serum osmolality, urine specific gravity -Assess nasal drainage for halo sign, glucose content -Manifestations of meningitis Actions: -Administer desmopressin or vasopressin as ordered -Maintain IV access and administer IV fluids as ordered -Administer humidified oxygen as ordered -Maintain HOB elevation 30 degrees -Provide adequate oral intake and mouth care q 4-6 hours -Avoid client straining, coughing blowing nose, vomiting -Manage moustache dressing Teaching: -Signs and symptoms of meningitis -Signs and symptoms of DI, fluid overload -Report an increase in drainage of clear fluid from nose -Avoid straining with bowel movements -Avoid tooth brushing for two weeks or may be allowed a soft toothbrush -Avoid activities after TPH (coughing, sneezing, blowing nose, or bending at waist) -Anticipate numbness in area, decreased sense of smell for up to 3-4 months

Nursing Management for acute pancreatitis

Interventions: Assessment: -Vital signs (temp, HR, RR, BP) -O2 status -Breath sounds -Pain (location, intensity, duration) -Abdominal assessment -Grey turner's and/or cullen signs -Serum amylase and lipase -Serum glucose -Serum calcium (trousseau's or chvostek's signs) -Stool color -Nutritional intake -Daily weight -Fluid intake and output Actions: - Maintain NPO status -Manage NGT to low intermittent suction -Promote bedrest -Position for comfort -Encourage coughing and deep breathing -Monitor BP, HR, CVP, PWP, I&O, skin turgor, capillary refill, mucous membranes and UOP (at least 0.5 ml/kg/hr) -Monitor for CMs of hemorrhage (H&H, Cullen's signs, Grey turner sign, abdominal girth) -Perform periodic glucose checks (accucheks) -Monitor for organ dysfunction: respiratory failure, paralytic ileus, mental changes -Prep patient for diagnostic testing -Administer medications as ordered Teaching: -Diet -Appropriate low fat, high carb diet and intake of small, frequent meals with vitamin supplements; no crash diets. -Abstain from alcohol and smoking -Assess for narcotic addiction -Disease symptoms, progression, diagnostic procedures and interventions; signs of infection, diabetes, steatorrhea.

Nursing Management: assessment, actions, teaching for pericarditis

Interventions: Assessment: -Vital signs HR, BP, RR, T -Pain -Heart sounds may sound more distant or muffled -ECG: ST & T waves Actions: -Keep head of bed elevated (position of comfort) -Provide rest -Administer analgesics, NSAIDS or steroid medications as prescribed to help reduce inflammation -Provide emotional support Teaching: -Do not abruptly stop steroids -Distinguish between pain of pericarditis and heart attack -Signs & Symptoms and treatment of disease -Indicators of pericardial effusion.

Nursing Management for Acute Kidney Injury

Interventions: Assessment: -Vital signs, ECG rhythm -Urine output -Laboratory values -Weigh patient daily -Oxygenation and breath sounds -Neuro assessment -Fluid overload manifestations Actions: -Manage fluid balance -Administer diuretics -Administer potassium-lowering therapy -Positioning, ambulation, cough and deep breathing exercises -Skin care, and oral care -Monitor and document food intake -Prevent and treat infection -Observe dialysis access site Teaching: -Knowledge of cause and treatment AKI -Fluid and dietary restrictions: Decreased sodium, Limited protein -Avoid nephrotoxic substances -Dialysis (if necessary) Prevention: -Identify and monitor patients at high risk -Control exposure to nephrotoxic drugs and chemicals -Prevent prolonged episodes of hypotension and hypovolemia -Monitor I&O, daily weight -Replace significant fluid losses -Provide aggressive diuretic therapy for fluid overload

Nursing Management of MS

Interventions: Assessment: a. Neuromuscular function Actions: - Encourage ROM - Administer Interferon -Administer corticosteroids during exacerbations -Implement safety measures Teaching: -Take medications as prescribed -Signs and symptoms of exacerbation -Review disease process and progress

Nursing Management of Pheochromocytoma

Interventions: Assessments: -Vital signs -Headache -Plasma catecholamine levels and catecholamines metabolites -Cardiac monitoring Actions: -Administer nitroprusside as directed -Administer alpha-blockers as prescribed -Administer beta blockers as prescribed -Bedrest with head elevated -Maintain calm, quiet environment Teaching: -Clinical manifestation adrenal insufficiency -Postoperative teaching related to adrenalectomy: Monitor body temperature, signs infection

Nursing management for Chronic liver failure

Interventions: Assessments: -Vital signs -Respiratory status, shortness of breath -Changes in mentation, presence of asterixis (neuro checks q2hrs & prn) -Fluid retention, peripheral edema -Abdominal girth, extremity measurement -Bleeding - gums, bruising, nosebleed, petechiae -Skin, sclera, urine, stool color, jaundice -I&O, daily weight -Acid base disorders (respiratory alkalosis; metabolic alkalosis) and Electrolyte imbalances (hypokalemia) Actions: -Administer diuretics -Administer electrolytes replacements esp. K+, Mg++, Phosphate -Restrict sodium and fluid intake as ordered -Restrict protein intake -Head of bed elevation and leg elevation -Administer Vitamin K, blood products, FFP as ordered -Promote rest periods between activities; sit during bathing and dressing -Skin care: Manage pruritus (Cholestyramine or hydroxyzine, Baking soda or Alpha Keri baths, Lotions, soft or old linen, Temperature control, Short nails; rub with knuckles)Special mattress & turn q2 hours -Provide oral hygiene Teaching: -Disease process -Diet restrictions (protein, sodium, fluid) -Adequate calories - 3,000 /day, moderate to low fat -Well-balanced diet in frequent small feedings -Rest -No alcohol intake, No smoking -Avoid eating raw shell fish, avoid hepatotoxic OTC drugs (Acetaminophen, ASA) -Medication education -Medical followup with lab value assessment -Protection from injury (soft toothbrush), careful flossing, electric razors -Health promotion: Reduce or eliminate risk factors, Treat alcoholism, Maintain adequate nutrition, Identify and treat acute hepatitis, Bariatric surgery for morbidly obese

Nursing management for acute liver failure

Interventions: Assessment: -Vital signs -Respiratory status, shortness of breath -Changes in mentation, presence of asterixis (neuro checks q2hrs & prn) -Fluid retention, peripheral edema -Abdominal girth, extremity measurement -Bleeding - gums, bruising, nosebleed, petechiae -Skin, sclera, urine, stool color - jaundice -I&O, daily weight -Acid base disorders (respiratory alkalosis; metabolic alkalosis) and Electrolyte imbalances (hypokalemia) Actions: -Administer diuretics -Administer electrolytes replacements esp. K+, Mg++, phosphate -Restrict sodium and fluid intake as ordered -Restrict protein intake -Head of bed elevation and leg elevation -Administer vit. K, blood products, FFP as ordered -Promote rest periods between activities; sit during bathing and dressing -Skin care: manage pruritus: cholestyramine or hydroxyzine, baking soda or alpha keri bats, lotions, soft or old linen, temperature control, short nails; rub with knuckles, special mattress and turn q2hr -Provide oral hygiene Teaching: -Disease process -Diet restrictions (protein, sodium, fluid) -Adequate calories: 3,000/day, moderate to low fat -Well balanced diet in frequent small feedings -Rest -No alcohol intake, no smoking -Avoid eating raw shell fish, avoid hepatotoxic OTC drugs (acetaminophen, ASA) -Medication education -Medical followup with lab value assessment. -Protection from injury (soft toothbrush), careful flossing, electric razors. -Health promotion: Reduce or eliminate risk factors, treat alcoholism, maintain adequate nutrition, identify and treat acute hepatitis, bariatric surgery for morbidly obese

Cardiac Catheterization

Is an invasive x-ray procedure during which a radiopaque catheter is advanced through an artery or vein to the heart under fluoroscopy in order to evaluate cardiac filling pressures, CO, and valvular function. Both right and left heart studies can be done through a suitable vein (femoral, brachial, subclavian). The catheter is advanced to the right heart via the inferior or superior vena cava. A left heart catheterization is done through a suitable artery (femoral, brachial, radial). The catheter is advanced up through the aorta and into the left heart.] a. Description - Invasive x-ray procedure to evaluate cardiac filling pressures, cardiac output, valvular function, coronary angiography (visualize coronary arteries) b. Risks/Complications i. Dysrhythmias ii. Bleeding/hematoma iii. Infection iv. Reaction to dye v. Myocardial infarction vi. Perforation of the heart or great vessels vii. Stroke viii. Acute kidney injury

Cardiac Output

Is the amount of blood ejected by the heart every minute. It is a function of stroke volume and heart rate (HR). It can be affected by many variables. Stimulus from the autonomic nervous system or hormones from the adrenal medulla can adjust the HR up or down. Changes in blood pressure sensed by baroreceptors can also affect HR.

Preload

Is the amount of blood in the ventricles at the end of diastole. It also refers to the amount of stretch of the muscle tissue at the end of filling. Increased volume produces increased stretch, which produces an increased contraction (starling's law). This is true up to a point. Extreme overfilling decreases the effectiveness of the contraction, thus decreasing Cardiac Output (CO). - Volume of blood in the heart before ejection.

Repolarization

Is the movement of ions back to the resting state; the cardiac resting membrane potential of -90 mV, to allow for the initiation of another action potential. Cells trying to get back to the original state of negativity. Move the polarity from positive to negative polarization.

Depolarization

Is the movement of ions proceeding and facilitating cardiac mechanical contraction. Cells have a negative charge at first. Move the polarity from negative to positive polarization.

Medical Management of Acute Kidney Injury

Lab studies: 1. BUN: 10-20 mg/dl, not a reliable indicator of kidney damage. 2. Serum creatinine: 0.7-1.4 mg/dl, more specific to kidney injury than BUN. 3. BUN/Creatinine Ratio: a) Normal between 10:1 and 20:1 b) Use this value to help determine the cause of AKI; and differentiate between acute and chronic renal failure c) An increased ratio may be due to a condition that causes a decrease in flow of blood to the kidneys, such as HF or dehydration 4. Urinalysis: a) Creatinine clearance to estimate GFR b) 24-hour urine; specific collection protocol c) Normal 120 mL/min d) Urine specific gravity 1.005 - 1.030 e) Urine osmolality 50-1200 mOsm/kg f) Urine sodium 40 -220 mEq/24 hours FENa (%) fractional excretion of sodium Diagnostic Studies: 1) X-rays (KUB) 2) Kidney ultrasonography 3) Renal scan 4) Computed tomography (CT) 5) Renal biopsy 6) Contraindicated: -Magnetic resonance imaging (MRI) -Magnetic resonance angiography (MRA) with gadolinium contrast medium: Nephrogenic systemic fibrosis, Contrast-induced nephropathy (CIN)

Medical Management for GI bleeding

Laboratory Studies: -Complete blood cell count (CBC): Hct and Hgb -Serum electrolyte (Na+, K+. BUN, creatinine) -Serum lactate -Prothrombin time, activated partial thromboplastin time -Arterial blood gases -Gastric aspirate analysis, guaiac testing -Liver enzymes Diagnostic Studies: -Endoscopy: diagnosis and treatment of UGI bleeding -Barium studies: evaluate ulcer/site of bleeding, tumors, and inflammatory processes -Angiography -Used when endoscopy cannot be done Goal of initial management: -Volume resuscitation. Other goals of management: -Hemodynamic stabilization -Identification of bleeding site -Initiation of definitive medical or surgical management to control or stop bleeding. Medications (decrease bleeding, neutralize HCL and decrease HCL secretion: -Proton pump inhibitors -H2 receptor blockers (histamine antagonists) -Somatostatin or Octreotide (when endoscopy not available) -Antibiotics (H pylori) -Vasopressin (esophageal varices) -Prokinetic agents (erythromycin or metoclopramide)- facilitate gastric emptying of retained blood Management of bleeding varices: -Endoscopy: cauterize, sclerotherapy, clip -Transjugular intrahepatic portosystemic shunt) (TIPS): nonsurgical treatment for recurrent bleeding, stent between hepatic and portal veins to reduce portal pressure. -Gastric lavage -Esophagogastric tamponade -Surgery for PUD or variceal bleeding: gastric resections, portal caval shunt. Complications: -GI hemorrhage -Hypovolemic Shock

Medical Management of Pericarditis

Laboratory and Diagnostic Tests: -12 lead ECG because of chest pain automatically because have to rule out an MI. -Chest x-ray to evaluate the size of the heart could be abnormal or enlarged heart. -Transesophageal echocardiogram (TEE) evaluate what is going on with the valves look for the presence of fluid in the pericardial sac. IF they had a chronic problem they could have a thickening of the pericardium and problems with contraction. -Cardiac enzymes a means to rule out an MI -Blood cultures figure out which organism is present to treat with right medication -CT, MRI more with chronic pericarditis done if trying to detect a thicker pericardium -CBC -C-reactive protein (inflammation), sedimentation rate Medications: -Antibiotics -Analgesics-ASA and non-steroidal agents not using opioids for these individuals. -Corticosteroids Complications: -Pericardial effusion this could lead to cardiac tamponade a) Procedures to relieve: Pericardiocentesis to remove the fluid from the pericardial space (pericardial drainage), pericardotomy/pericardial window, pericardectomy - Cardiac tamponade a) Manifestations: decreased CO, muffled heart sounds (classic manifestation for this), narrowed pulse pressure, JVD (pressures building up in those chambers), pulsus paradoxus, circulatory collapse (tachypnea, tachycardia, hypotension), dyspnea

Medical Management of Endocarditis

Laboratory and Diagnostic Tests: -Blood cultures (need identification of organism) to help target the right antibiotics for treatment. Repeat culture until negative results (no growth). -12 lead ECG allow us to see the impact on their cardiac function. -Echocardiography (TTE, TEE) used to evaluate the function of the valves and see their involvement in this condition. Preventive Care: -Prophylactic antibiotic treatment for select clients with: certain dental procedures, respiratory tract incisions, tonsillectomy, adenoidectomy, GI wound infection, urinary tract infection. Medications: -Antibiotics IV(combination therapy; duration 4-6 weeks [longer with prosthetic valve]). -Antifungal (fungal infections-Amphotericin B) most common used. -Antipyretics if they have a fever. General management: -Fluids -Rest.

Invasive Hemodynamic monitoring

Line that goes directly into the body. 1. Hemodynamic monitoring system 2. Arterial Catheters 3. Central venous catheters

Lung Zones

Look at V/Q ratio in these 3 different zones. -Zone 1: standing upright the alveolus is getting more flow of ventilation, getting less circulation due to gravity. Alveoli are being well ventilated but perfusion and transport of gases may be impaired. -Zone 2: equally influenced on the alveoli and capillaries so the alveoli are being ventilated but not as much as zone 1 and then capillaries are still perfusing and probably a little more than zone 1 because there's less impact from gravity. -Zone 3: not ventilating those alveoli because they are at the lowest point so you see the alveolus is much smaller but because of gravity we have better perfusion now we have more perfusion then ventilation.

Treatment for ARDS

Mechanical ventilation: 1) Treat refractory hypoxemia - mechanical vent (V-A/C) with reduced tidal volumes and PEEP (monitor for hypercapnia) 2) Other modes: Airway release ventilation, inverse ratio ventilation; high frequency ventilation, permissive hypercapnia, Pressure control ventilation be familiar with for test 3) Extracorporeal membrane oxygenation (ECMO) Positioning: 1)Proning with mechanical ventilation 2) Goal to increase PaO2 3)Recruit collapsed alveoli 4)Dependent areas of lungs are more heavily damaged than nondependent areas 5)More effective in the early stages Medications: 1) Antibiotics 2) Steroids 3)Sedatives, neuromuscular blocking agents or paralytics Adequate hydration: 1) Adequate blood volume to maintain organ perfusion 2)Avoid thick, dry secretion, mucous plugs 3)Diuretics to reduce risk for pulmonary edema 4)Crystalloids, colloids e) Improve O2 carrying capacity of blood: Administer packed RBCs (keep Hgb 7g/dL) f) Nutrition:Enteral is preferred over TPN or parenteral feedings - initiate in 48 - 72 hours of initiation of mechanical ventilation Complications: a) Barotrauma b) Renal failure/Multiorgan dysfunction syndrome c)Ventilator associated pneumonia

Nutritional and Surgical Management of ICP

Nutritional management: -Hypermetabolic and hypercatabolic state ↑ need for glucose -Enteral or parenteral nutrition -Early feeding (within 3 days of injury) -Keep patient normovolemic. -IV 0.9% NaCl preferred over D5W or 0.45% NaCl because the other two become hypotonic in the body. Want a solid isotonic solution such as IV 0.9% NaCl Surgical management: -Hemicraniectomy with durotomy (a) Remove section of cranium and dura (b) Creates space for swelling brain (c) Skull removed and stored in tissue bank or in a tissue pocket with patient's abdomen (d) Replace dura with synthetic material that allows for expansion by closes the meningeal layer

Endotracheal Intubation

Prep: -Consent -Client teaching Equipment: -Self-inflating BVM/Ambu bag attached to oxygen -suction equipment -IV access Intubation procedure: a) Before intubation -Sniffing position -Pre-oxygenate using ambu bag with 100% O2 for 3-5 minutes -Limit each intubation attempt to <30 seconds b) During intubation -Coordinate care of client -Monitor client continuously (vital signs, O2 sat) -Assess for signs of: hypoxia, dysrhythmias, aspiration -Ventilate patient between successive attempts using ambu bag with 100% O2 -Administer sedation and/or neuromuscular blocker as ordered to promote comfort & synchrony with ventilator -See handout "Neuromuscular blockers, sedation and antagonists c) After intubation -Inflate cuff, confirm placement of ET tube and secure tube -Auscultate x5 locations 2 on the upper chest, 2 on the lower chest, and one over the stomach. Should be able to hear air moving in the upper and lower chest but you should not hear air over the stomach. -lungs bilaterally x4 (anterior and lateral), epigastrium x1 -End-tidal CO2 detector (color change indicating presence of CO2) -Esophageal detector device -Observe chest wall movement -Secure tube and record cm at the teeth or gum for reference -Suction oropharynx and ET tube as needed -Monitor oxygen saturation -Document procedure -Get stat chest x-ray (2-6 cm above carina) 2)Complications: -Unplanned extubation -Aspiration -Infection

Medical Management of Stroke

a) Goal to restore blow flow blocked vessel b) IV recombinant tissue plasminogen activator (rt-PA): -Give within 3 - 4.5 hours onset of symptoms -Contraindications why we would not give tpa: (a) Intracranial hemorrhage (b) Minor or rapidly resolving symptoms (c) Active internal bleeding (GI or renal in last 21 days) (d) Major surgery or serious trauma in last 14 days (e) Stroke, head trauma, intracranial surgery in last 3 months (f) Systolic BP > 185 or diastolic BP > 110 at admission (g) Recent MI (h) Refer to facility's inclusion/exclusion checklists for full list c) Intra-arterial thrombolytic administration: -Performed in interventional radiology -May use a clot retrieval device d) Prevent complications of stroke: -VTE prophylaxis -Manage blood pressure -Control risk factors -Find cause of stroke -Antiplatelet medications at discharge -Lipid-lowering agents at discharge -Anticoagulation at discharge if atrial fibrillation

Medical Management of Aortic Aneurysm

a) Goals: 1) Monitor growth of aneurysm over time 2) Risk factor modification 3) Maintain normal blood pressure to prevent rupture b) Aneurysm less than 5 cm in diameter c) Small or asymptomatic aneurysms will require regular ultrasounds or CTs every 6-12 months to monitor size d) Diagnosis: 1) CT with contrast 2) Abdominal ultrasound or transthoracic echocardiography (TTE) 3) MRI 4) 12 Lead ECG to make sure not having an MI e) Medications: 1) Antihypertensives (ACEI and or ARB) 2) Antibiotics (Macrolides or tetracyclines -prevent secondary infection) 3) Statins (may be utilized) if need to lower lipid profile.

Pressure Support Ventilation (PSV)

a) Independent mode or used with SIMV or CPAP b) Gives set positive pressure during spontaneous inspirations c) Client breathes spontaneously with client's own volume, rate, and inspiratory time but has continuous positive airway pressure maintained during inspiration d) Reduce workload of breathing and keeps alveoli open e) Usual setting: 5-10 cm H2O

Renal replacement therapy (RRT) for acute kidney injury

a) Indications: -Volume overload -Elevated serum potassium level -Metabolic acidosis -BUN level higher than 120 mg/dL (43 mmol/L) -Significant change in mental status -Pericarditis, pericardial effusion, or cardiac tamponade

Other settings on mechanical ventilator

a) Inspiratory flow rate and time b) Sensitivity c) Alarm settings

Rate for mechanical ventilator

a) Number of respirations the client receives per minute via the mechanical ventilator b) Setting depends on the mode selected c) When assessing client's respiratory rate, include both the ventilator and spontaneous breaths d)Usual setting: 6 - 20 breaths/min

Abdominal Aortic Aneurysm (AAA)

a) Pain - abdomen or lower back b) Palpable mass c) Bruit over abdominal aorta, or pulsation in upper abdomen; may feel heartbeat d) Rupture of AAA aneurysm manifestations: -Embolization of clot or plaque (pain, numbness, tingling, cyanosis) -Symptoms of hypovolemic shock -Pain - sudden ripping, tearing, stabbing abdominal, back or leg pain -Rupture into retroperitoneal space (bleeding, severe back pain, Grey Turner's sign (Turner's sign)

Continuous Positive Airway Pressure (CPAP)

a) Pressure delivered continuously during inspiration (spontaneous breaths) b) Increased work of breathing. c) No rate or tidal volume set d) Risk for apnea -No rate or tidal volume set, client controls rate and tidal volume. -Anticipated settings: Pressure support, PEEP, FiO2.

Oropharyngeal Airway

a) Prevent airway obstruction from tongue relaxation, secretions, seizures or biting on oral ET tubes b)Measure for the appropriate size c) Remove every 24 hours to check for pressure & provide oral hygiene d) Use only in unconscious/semiconscious patients

Nasopharyngeal Airway

a) Provide an airway b) Measure for correct size c) Lubricate prior to placement d) Complications - bleeding, sinusitis, erosion of mucous Membranes

Synchronized Intermittent Mandatory Ventilation (SIMV)

a) Provides ventilator-assisted breaths and spontaneous breaths b) If client does not initiate a breath, ventilator delivers preset volume and rate per minute c) Mode allows client to breathe spontaneously at his own rate between breaths given by the ventilator d) Synchronizes with client's effort to breath -Client controls volume on spontaneous breaths. -Anticipated settings: Rate, Tidal Volume, Pressure Support, PEEP, FiO2

Hypermagnesemia

a) Rare b) ECG Changes: Like Hyperkalemia c) Causes: -Renal dysfunction -Tumor lysis syndrome -Over treatment

Client Criteria for Weening

a) Reversal of underlying cause of respiratory failure b) Hemodynamic stability c) Adequate respiratory muscle strength to initiate inspiratory effort d) Able to maintain: -pH > 7.25 during spontaneous ventilation -PEEP < 5-8 cm -FiO2 < 40-50% -PaO2/FiO2 ratio > 150-200

Methods of weaning

a) Spontaneous breathing trial (SBT): -Pressure support -CPAP -T-piece trials b) If client tolerates SBT for 30 - 120 minutes without tachycardia, hypertension, hypotension, deteriorating ABG results, or dysrhythmias, client usually extubate

Organ Donation

a. Must be legally competent to donate any body part (organ or tissue) or entire body: -Donor card, driver's license, donor registry -Person's legal next of kin must consent at death regardless of signed donor card -Clients have a right to decide to become an organ donors -Clients have a right to refuse organ donation or transplant -Clients 18 years or older May choose to donate organs b. Organ sharing network: -United Network for Organ Sharing (UNOS) -Regional, state, and national networks -Manage national transplant waiting list, matching donors to recipients c. Description: -Some tissues must be used within hours after death -Common tissue transplants: Corneas, skin, bone marrow, heart valves, bone and connective tissue -Transplanted organs: Heart, lungs, liver, kidneys, pancreas, and intestine -Sources: Deceased (cadaver), Living donor -Tissue typing: Blood type - ABO blood group, HLA typing - try to match at least 5 or 6 antigens, Crossmatch - check for pre-formed antibodies to potential organ, Weight -Organ donation after brain death: 1. Collaborative practice 2. Phase I - Referral 3. Phase II - Declaration of brain death, obtaining consent: Request to the family are usually completed by the representative from Organ Donation Center, Religious beliefs should be given consideration when approaching the family 4. Phase III- Donor evaluation 5. Phase IV - Donor management 6. Phase V - Recovery phase -Organ donation after cardiac death: 1. Specific criteria 2. Withdrawal of life-sustaining measures 3. Pronouncement of death 4. Organ viability 5. Ethical considerations

Liver Transplant

a. Postoperative care: -Airway management and respiratory support (ventilator) -Stabilize temperature and monitor hemodynamics -Assess neuro, renal functional, & presence of coagulopathies -Maintain glycemic control: continuous insulin drip. -Manage tubes/ drains - t-tube, nasogastric tube -Monitor key lab values - LFTs, electrolytes, albumin, coagulation studies -Complications: 1. Graft rejection: Detected by liver biopsy 2. Infection (peritonitis, sepsis) 3. Pulmonary complications (pleural effusion, pulmonary edema, pneumonia, paralysis of right diaphragm) 4. Kidney problems 5. Biliary leaks or obstruction 6. GI bleeding/ ulceration 7. Bowel perforation Client education: 1. Medications 2. Home assessment - temperature, BP, HR 3. Incision care 4. Prevention of infection 5. When to call HCP 6. Follow-up with HCP

Arterial Catheters

a. Purpose: Measure continuous systemic blood pressure directly in an artery. b. Uses: 1. Evaluate interventions continuously, including vasoactive medications. @. Obtain arterial blood samples. c. Location: 1. Radial 2. Other arteries utilized: femoral (only use for 24 hrs), axillary) may lead to problem with spasms), brachial (may lead to problems with spasms). d. Normal values: 1. systolic pressure (SBP) 100-120 mmHG 2. diastolic pressure (DBP) less than 80 mmHg. 3. Mean arterial pressure (MAP) 70-90 mmHg. e. Nursing implications f. complications

Nitrates for STEMI

o Action: vasodilation, decreases pain, increases venous capacitance, helps prevent coronary vasospasm, decreased preload and afterload o Treat angina symptoms, hypertension and heart failure during STEMI o Sublingual nitroglycerin tablets given every 3-5 minutes with maximum dose of 3 tablets to relieve angina o IV nitroglycerin for persistent angina

Aldosterone Antagonists for STEMI

o Spironolactone o Recommended for patients with Unstable angina/NSTEMI if LVED (EF <60%) and either diabetes or symptomatic heart failure

Insufficiency

or regurgitation where the valve cannot close completely

Respiratory Alkalosis

pH >7.45 PaCO2<35 Causes: -neurogenic hyperventilation -interstitial lung disease -pulmonary embolism -asthma -anxiety, stress, fear -hyperventilation syndromes -severe hypoxemia -pain Clinical Manifestations: -lethargy, lightheadedness, confusion -tachycardia -dysrhythmias related to hypokalemia -nausea, vomiting, epigastric pain -tetany - tingling of extremities -hyperreflexia -seizures -hyperventilation Collaborative Management: -treat underlying cause -monitor for respiratory distress, monitor electrolyte values esp. K+ and Ca++ -decrease excessive ventilation if possible (hyperventilation-encourage breath holding) -if hypoxemia, provide oxygen -if anxiety, provide reassurance and emotional support -whenever abnormal respiratory rate, find cause -administer calcium for tetany

Metabolic Acidosis

pH<7.35 HCO3<22 Causes: -increased metabolic formation of acids (DKA, uremic acidosis, lactic acidosis -loss of bicarbonate (diarrhea, renal tubular acidosis) -hyperkalemia -toxins (salicylate overdose, ethylene & propylene glycol, methanol, paraldehyde) -adrenal insufficiency Clinical Manifestations: -headache -confusion, drowsiness, coma -hypotension -dysrhythmias due to hyperkalemia -warm, flushed skin (peripheral vasodilation) -nausea, vomiting, diarrhea, abdominal pain -deep, rapid respirations Collaborative Management: -treat underlying cause -monitor for respiratory distress, CNS depression, I&O, monitor electrolyte values esp. K+ -decrease acid formation (decrease lactic acid production by improving CO in shock) -treat DKA with insulin and IV fluids -treat kidney disease with dialysis, low protein/high calorie diet to reduce acidosis -decreased bicarbonate losses (treat diarrhea, remove toxins with dialysis or cathartics) -administer sodium bicarbonate (in extreme metabolic acidosis) -identify patients at risk - diabetes, sepsis, renal disease, hypoxic and malnourished

Nursing Considerations with Artificial Airways and Ventilators:

• Always have an ambu bag and mask at bedside (ICU) and on crash cart (all other units). • Have suction equipment set up at bedside (ICU) and on crash cart (all other units). • Assess need for suction q 1-2 hours. Suction only when needed. Insert catheter until client coughs or meet resistance (which ever occurs first). • Have spare airway the same size at the bedside (or 1 size smaller if directed). • Assess depth of ET tube at the teeth or gum and security of the tube q 2 hours and prn. • Assess for air leak around cuff (client speaking, air hissing or decreased SaO2) • Assess cuff pressure at least every 8 hours. Maintain cuff pressure 20-25 mmHg to reduce tracheal necrosis. Respiratory therapy checks pressure in cuff with pressure manometer) • Monitor pulse oximetry continuously. • Assess vital signs and breath sounds q2 hours and prn. • Check ventilator settings q2 hours and prn. • Troubleshoot alarms as needed. • Monitor I & O. • Monitor for complications: decreased cardiac output/ hypotension, infection, barotrauma, aspiration, stress ulcers/GI bleeding, ventilator associated pneumonia (VAP), anxiety, failure to wean, fluid retention, pneumothorax, oxygen toxicity. • VAP Bundle - increase HOB, DVT prophylaxis, PUD prophylaxis, oral hygiene care with chlorhexidine, daily sedation vacation and assessment of readiness to extubate. • Never shut alarms off, silence only • Be prepared to manually ventilate the client using ambu bag/O2 if uncertain of problem

Third Link Defibrillation outside the hospital

• Automated External Defibrillator (AED) is used when the heart needs to be reset by an electric shock • When applying pads consider: -Removing excess hair to get good contact with the skin -Dry chest if visibly wet -If an implanted pacemaker or defibrillator is detected place the AED pad at least 1 inch away from implant and NEVER place pad on top of device -Always remove medication patches and clean area before placing pads

Post Cardiac Rest

• Controlled cooling of the body core temperature • Goal: Decrease cerebral metabolic rate and decrease brain injury, Temperature is between 28°C to 32°C • Benefits include decreases in morbidity and mortality rates • Time of cooling a. Immediately after return of spontaneous circulation (ROSC) b. 12-24 hours of cooling c. 12 hours to warm the patient back up d. Total of 36 hours • Cooling Techniques/Monitoring: a. Cooling blankets b. Pack patient in ice c. Cold wet towels d. Cooling helmet e. IV crystalloid at 4°C given over 30 minutes f. intravascular heat exchange device, which enables rapid cooling and precise temperature control • Collaborative care: a. Monitor airway and mechanical ventilation b. Monitor core temperature c. Monitor shivering and control with sedatives, analgesics, neuromuscular blocking meds d. Prevent infection e. Management hyperglycemia f. Monitor electrolytes - K+, Mg++, PO4, Ca++ g. Rewarm after 24 hours very slowly h. Monitor for complications: Infection, dysrhythmias, bleeding

Chain of Survival

• In hospital, cardiac arrest (IHCA)

Second Link Immediate high quality CPR

• Out of hospital cardiac arrest • Compression only CPR for adults • Conventional CPR for infants and children • HCP - call for nearby help or activate emergency call system and can simultaneously check for breathing and pulse. • VT/VF - Shock first or Compressions first? compressions first and then use an aed to shock them back into rhythm. • Single rescuer: initiates compressions before giving breaths CPR: (C-A-B) • C: Compressions: High-quality; push hard and fast at rate of 100 - 120 x/min; compression depth of at least 2 inches and not more than 2.4 inches; allow chest recoil; minimize interruptions < 10 sec. • A: open airway: Perform a head tilt; chin lift or jaw-thrust • B: Breathing • if breathing or resumes breathing, place in recovery position • if not breathing, give 2 breaths to make the chest rise, allow for exhalation between breath, then resume chest compressions • Deliver breath over 1 second; if rescue breathing, give 1 breath every 6 seconds (10 BPM)